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Abortion

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CHIV. 8/18/09. Abortion. Joanne Fletcher. Consultant Nurse Gynaecology. STHFT. 8/18/09. CHIV ... This represents 82 million unplanned pregnancies each year ... – PowerPoint PPT presentation

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Title: Abortion


1
Abortion
  • Joanne Fletcher
  • Consultant Nurse Gynaecology
  • STHFT

2
Learning outcomes
  • Abortion statistics
  • Sheffield TOP service
  • Methods of abortion
  • Consent
  • Confidentiality

3
Pregnancy Statistics Global Overview
  • Each year 205 million women become pregnant
  • Approximately 40 of these pregnancies are
    unplanned
  • This represents 82 million unplanned pregnancies
    each year
  • Approximately 42 million abortions occur each
    year (22)
  • Approximately 115,000 abortions each day 83 of
    these are in developing countries
  • An estimated 43 of all women will have at least
    1 abortion by the time they are 45 years old
  • Worldwide the lifetime average is about 1
    abortion per woman
  • Guttmacher Institute 2008 www.agi-usa.org

4
Number of Abortions carried out in England
Wales 1976-2008
5
Number of Abortions carried out in England
Wales by year month
6
2008 data England Wales
  • the total number of abortions was 195.296
    compared with 198,500 in 2007, a decrease of 1.6
  • Abortion rate 18.3/1000 women in England,
    (16/1000 in Sheffield)
  • Abortion rate highest at 36 per 1000, for women
    aged 19yrs (12), same as 2007
  • Under 16 abortion rate 4.2 per 1000, under 18
    rate was 18.9 per 1000 (10), both slightly less
    than 2007
  • Biggest rate in 20-24 yrs group 28.6
  • 98 abortions carried out under section C of
    Abortion Act 1967, 1 under ground D, 1 under
    ground E
  • DH abortion statistics for 2008 (published May
    2009)

7
Sheffield Integrated Termination of Pregnancy
(TOP) Service
  • Approx 1850 abortions/ year in Sheffield from
    approx 2200 referrals (not including fetal
    anomaly)
  • Majority referred through Central Health Clinic
    (SCaSH)
  • gt14 wks or complex medical problems directly
    referred STHFT (RHH)
  • All patients have treatment in a dedicated
    abortion unit at RHH ward G1
  • Integrated referral pathway

8
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9
RCOG Referral Guidelines
  • Ideally, all women requesting TOP should be
    offered a counselling appointment within 5 days
    of referral
  • Ideally, all women women should be able to
    undergo TOP within 7 days of decision to proceed
    being agreed
  • As a minimum standard, all women should be able
    to undergo TOP within 2 weeks of decision to
    proceed being agreed

10
Methods of abortion
  • Surgical ( Aspiration/ DE)
  • Manual Vacuum Aspiration
  • Medical
  • May need referral to other provider (e.g. bpas,
    MSI) if greater than 18 weeks gestation

11
Surgical abortion
  • Most common abortion procedure (75 nationally)-
    usually daycase
  • Can be performed up to 15 weeks (only 12 weeks in
    Sheffield) usually under GA
  • Cervix primed with misoprostol 2 - 3 hours
    prior to procedure
  • Complication rate lt2

12
Manual Vacuum Aspiration under LA
  • Day case - usually only 6 hours in hospital
  • complication rate less than 1
  • patient awake during procedure
  • given oral sedative, anti-inflammatory
    suppository and vaginal prostaglandin's 2-3 hours
    prior to procedure

13
Medical abortion
  • 2 visits day 1 anti-progestogen, day 3
    prostaglandins
  • lt9 wks 6-8 hour stay
  • 9-12 wks possible overnight stay (4)
  • gt12 approx 7 overnight stay approx 1-2
    require ERPC
  • Approx 5 complication rate (depends on
    gestation)

14
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15
Percentage of abortions by method (all
gestations) England Wales
16
Complications (all procedures/ gestations)
  • Uterine perforation (Surgical only) (lt1)
  • Cervical trauma (surgical only) (lt1)
  • Haemorrhage (lt1)
  • Failed abortion/ongoing pregnancy (1-2)
  • Post abortion infection/Endometritis (lt1)
  • Retained Products of Conception (2-4)
  • Psychological sequelae (??10)
  • Future reproductive outcomes (lt1)

17
Pre - assessment
  • Medical/ obstetric history
  • Scan (lt8 weeks usually TVS)
  • Sexual health screen chlamydia, gonorrhoea
  • Bloods FBC, GS, Rubella
  • Info re methods ( potential complications)
    appropriate to gestation
  • Written consent
  • Legal Abortion Act forms (HSA1/HSA4) completed
  • Medication prescribed
  • Contraception discussed prescribed/ arranged
  • All offered counselling with specially trained
    counsellors at CHC (mandatory for under 18 years
    always seen alone)

18
Competent minors (aged 16-17 years)
  • Entitled to consent to own medical treatment
    (section 8 of Family Law Reform Act 1869)
  • However, refusal can be overridden by person with
    parental responsibility/ court
  • Same criteria applied re capacity as for adults
  • Good practice to include family in decision
    making but not necessary

19
Competent minors (under 16 years)
  • Gillick case HC(FP)(86)1 any competent young
    person, regardless of age, can give consent to
    medical treatment
  • Fraser criteria formed in relation to
    contraceptive advice refusal to inform parents
  • Mansfield case
  • Doctor justified in proceeding without parental
    consent if
  • Understands advice
  • Cannot persuade/ allow him/her to inform
  • Likely to begin/ continue having SI with/without
    contraception
  • Physical/mental health might suffer without
  • Best interests to acquire contraception

20
Confidentiality
  • Right to confidentiality arises from
  • Duty of care in negligence (civil)
  • Implied duties on a contract of employment
  • Duty to keep a confidence even without a
    pre-existing relationship/contact
  • Article 8 of The Human Rights Act 1998Right to
    respect for private and family life

21
Confidentiality abortion
  • All women (including lt16 yrs) seeking abortion
    have right to confidentiality from all clinical
    and ancillary staff
  • HCP have a duty via the Fraser Guidelines to try
    persuade minor to tell parents/ guardian
  • Requires responsible adult to act as loco
    parentis for minors
  • Only breach in exceptional circumstances e.g.
    health welfare of minor (safeguarding issues),
    or other persons at risk
  • Notified centrally to Chief Medical Officer via
    HSA4 form

22
Exceptional circumstances
  • Wards of court
  • Non-competent minors
  • Non-competent adults
  • Child protection issues (lt13 years/ sexual
    exploitation)
  • Rights of spouse or partner no rights legally
    to demand or refuse termination

23
Summary
  • Abortion free to all Sheffield women
  • Direct referral to abortion service via CHC or GP
  • Important to access services earlier as increases
    options and gives longer time to consider
    decision/ choices
  • Abortion available up to 18 weeks gestation in
    Sheffield, after 18 weeks referred to bpas
  • Abortions performed earlier are safer
  • All women offered counselling mandatory if less
    than 18 years

24
Useful websites
  • www.abortionrights.org.uk
  • www.efc.org.uk (education for choice)
  • www.ippf.com (International planned parenthood
    foundation)
  • www.brook.org.uk (Brook Advisory Service)
  • www.fpa.org.uk (Family Planning Association)
  • www.rcog.org.uk (Royal Collage of Obstetricians
    Gynaecologists)
  • www.dh.gov.uk (for teen pregnancy/abortion
    statistics, DH documents)

25
Thank you!
  • joanne.fletcher_at_sth.nhs.uk
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