Unsafe abortion worldwide

1. 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)

2. 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

3. The current state of PAC in many health clinics • Medical equipment is obsolete or in poor condition • Abortion patients are not treated with respect and sympathy • Services are not well organized and supervision is poor • Services are not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

4. Potential difficulties in providing PAC services 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

5. Potential difficulties in providing PAC services (cont’d) 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)

6. 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 Elements and Purposes of PAC elements

7. 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

8. Empathetic people are: • Genuine, pleasant and friendly • Honest • Quick to establish relationships with others • Compassionate • Helpful • Good listeners • Gentle and affectionate • Nonjudgmental

9. 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

10. 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

11. 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

12. 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. • How do you know if a person is really listening? • How do you know when someone is not listening?

13. Information Accessible services Safe services Choices Privacy Confidentiality Dignity Comfort Opinions Follow-up care Patients’ rights All patients have the right to:

14. 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

15. 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.

16. 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.

17. Bimanual Exam

18. 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.

19. 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).

20. 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.

21. 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

22. Ways that pain is amplified Fear Stimulus Tension Pain CNS Response

23. To minimize the woman’s anxiety and discomfort with the least amount of risk to her health LEAST RISK LEAST PAIN Goal of pain management

24. Cervical dilation and/or stimulation Types and origins of pain Deep intense pain Scraping of uterine wall, movement of uterus or muscle spasms Diffuse lower abdominal pain with cramping

25. Nerves that transmit pain T 1 2 L 1 L 2 L 3 L 4 Hypogastric plexus -- body, fundus of uterus Uterovaginalplexus -- cervix, upper vagina S 2 U t e r u s S 3 S 4 C e r v i x V a g i n a t e r o v a i a l p l e x u s : c e r v i x , u p p e r v a g i n g

26. 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 Requirements for effective pain management

27. 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

28. Analgesia - eases sensation of pain Anxiolytic - depresses central nervous system functions (reduces anxiety, relaxes muscles) Anesthesia - deadens all physical sensation Types of pain medication

29. Preferred characteristics of anesthetics for use with MVA • Rapid-acting • Easy-to-use • Low-risk • Induces amnesia • Quick recovery • Low-cost

30. 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 Types of anesthesia

31. Gentle handling of the patient The proper combination of drug types (anesthetics and analgesics) Effective pain management for MVA

32. Use a 22-gauge spinal needle or needle extender with a 10cc syringe. Aspirate before each injection. I n j e c t i o n S i t e s Paracervical block

33. 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 O p t i o n a l I n j e c t i o n S i t e s I n j e c t i o n S i t e s Paracervical block (cont’d)

34. 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

35. 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 Complications of local anesthetics

36. 36 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.

37. 37 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

38. 38 Two types of vacuum aspiration ElectricManual Electric pump Manual syringe Constant suction Suction not constant 350 – 1,200 cc of storage capacity 60 cc of storage capacity CannulaeCannulae Rigid or flexible Flexible Diameter of 4 to 16 mm Diameter of 4 to 12 mm

39. 39 Efficacy of MVA Adapted from Greenslade et al. 1993

40. 40 Safety • Rate of complications in vacuum aspiration (electric and manual) vs. D&C in abortion • reported in JPSA study Percentage of women sustaining complications Adapted from Grimes et al. 1977

41. 41 Average Number of Complications per 100 Procedures in Six Studies Comparing Vacuum Aspiration and Sharp Curettage Adapted from Baird et al. 1995.

42. 42 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

43. 43 Resource savings associated with MVA Decrease in costs in Kenya Decrease in length of hospital stay in Mexico Average cost per patient in $US Average time in hours Hospital 1 Hospital 2 Hospital 1 Hospital 2 Adapted from Johnson et al. 1993

44. 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 44 Comparison: Treatment of incomplete abortion *Efficiency is defined as a successful uterine evacuation with no remaining tissue

45. 45 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

46. 46 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

47. 47 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.

48. 48 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

49. 49 Selecting the cannula Adapters for the double-valve syringe are color-coded to the dots on the corresponding cannula.

50. 50 Selecting adapters Select the adapters based on the cannula and the type of syringe to be used