Options Counseling for Unintended Pregnancy

1. Options Counseling for Unintended Pregnancy

2. Objectives • To identify the knowledge, skills and attitudes needed to provide care to women with unintended pregnancy • To understand professional, ethical issues of facilitating non-directive early pregnancy decision-making.

3. Background on Unintended Pregnancy Each year in the United States: 48% of pregnancies are unintended: Approximately half are carried to term or end in miscarriage Approximately half are terminated Women with unintended pregnancies are from all races, ethnicities, classes, and religions.

4. What skills do nurses/APRNs need to provide care to women with unintended pregnancy? Attitude, skills and knowledge

5. Attitude needed by RN/ APRNs to provide options counseling • Inform and educate self on: • Providing care in a sensitive, respectful manner, acknowledging the need for privacy and confidentiality. • Using language that is sensitive and respectful.

6. Skills needed by RN/APRNs to provide options counseling Providing non-judgmental, non-directive counseling using specific counseling techniques. Addressing issues of ambivalence. Supporting the woman in her decision-making. Assuring that the informed-consent process includes appropriate, accurate information about the potential benefits and risks of abortion, adoption and continuing the pregnancy. Providing resources or referrals to quality providers.

7. Skill: Provide options counseling using non-judgmental, non-directive counseling techniques to promote effective communication: • Asking questions • Reflecting • Normalizing • Examining consequences • Reframing

8. Skill: Counseling • If the woman appears too overwhelmed to respond to the news of an unintended pregnancy, give her time to absorb the news • Assist the woman to identify support systems and access risks • Discuss a timetable for decision-making

9. Skill: Informed consent • Principles of informed consent: • Client must have appropriate information to make an informed decision • Decision-making is not coerced or manipulated • Client is capable of understanding information and making a decision

10. Knowledge needed by RN/APRNs to provide options counseling Inform and educate self about: • Providing the full range of pregnancy options. • Counseling on prenatal, adoption or abortion care. • Assisting women with selecting an acceptable contraceptive method.

11. Knowledge needed by RN/APRNs to provide options What are a woman’s options?   Continue pregnancy and: parent make an adoption plan Terminate pregnancy through: medication abortion aspiration abortion

12. Counseling: Continuing the pregnancy • Provide education about the effects of alcohol, drug use, smoking, toxins and medications on a developing pregnancy. Review current medication use. • Screen for any personal or family history of genetic diseases that may require a consult with a genetic specialist. • Provide a prescription for prenatal vitamins (which include folic acid 1mg). • Provide referrals for prenatal care. • Is woman interested in midwifery care? • If financial resources are limited, is she eligible for Medicaid, WIC, or other programs?

13. Early pregnancy health concerns for any woman with an unintended pregnancy • Does the woman have any immediate social concerns? • Does the woman need nursing support or medical management for nausea of pregnancy? • Screen for domestic violence. • Screen for abdominal/pelvic pain with vaginal bleeding. If present, refer the woman for an immediate workup for a possible ectopic pregnancy.

14. Counseling: Choosing adoption • Applies skill in nondirective counseling • Knowledge of different types of adoption: • Open, closed, familial adoption, state adoption or foster care • Management of or referral for adoption services

15. Positive Adoption Language POSITIVE NEGATIVE Giving your child away Putting your child “up” for adoption Keeping the child “Real” or “natural” mother/father/parents Keeping the child • Planning an adoption for your child • Choosing an adoptive family for your child • Birthmother, birthfather, birthparent • Deciding to parent the child Adapted from Open Adoption & Family Services www.openadopt.org

16. Counseling: Choosing an abortion Knowledge 88% are done in the first 12 weeks of pregnancy 95% performed in outpatient setting Actual procedure takes less than 5-10 minutes in most cases Local anesthesia used; may opt for conscious sedation or general anesthesia In outpatient settings, average cost $468

17. Method of Abortion: Medication Advantages: • May offer more privacy • Can occur in comfort of home • Avoids instrumentation procedure Considerations: • Two medications: mifepristone administered in the office & misoprostol self administered at home. • Takes 4-6 hours (on average, maybe longer) to complete abortion at home. • If unsuccessful, requires f/u aspiration intervention. • Currently used for abortions up to 10 weeks gestation.

18. Method of Abortion: Vacuum Aspiration Advantages: • Procedure complete within minutes during one visit • High success rate • Can be performed into second trimester Considerations: • Involves instrumentation procedure • Similar cost to medication option • Can be performed with manual vacuum or electric vacuum aspiration

19. Aspiration abortion procedures Methods and timing: Vacuum aspiration Up to 14-15 weeks Dilation and evacuation 15-23 weeks Induction or instillation Used <1% of procedures, usually between 20-23 weeks

20. Summary: Suggested steps in pregnancy options counseling Explore how the woman is feeling about the positive test result. If she is unsure of her plans, help her to consider her alternatives. Many women will know what they want to do. Help her to identify support systems. If she is not ready to make a decision, discuss a timetable for decision-making after estimating gestational age by LMP and/or clinical exam and/or ultrasound to determine gestational age. Refer or provide her with appropriate information about abortion or adoption services.

21. Professional responsibilities • Engage in self reflection and values clarification about the intersection of personal beliefs and professional responsibilities. • Uphold the woman's autonomy and right to care. • The ANA Code of Ethics offers an ethical framework for approaching nursing care.

22. For further information, visit Reproductive health in Nursing www.rhnursing.org