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Rh negative women who become exposed to Rh positive blood may become ‘alloimmunized,’ or develop anti-Rh antibodies. Women with Rh alloimmunization may have complications in future pregnancies, including hemolytic disease of the newborn. Rho (D) immunoglobulin (marketed as RhoGAM, containing 300 mcg) was developed to prevent the maternal formation of anti-Rh antibodies, and is routinely given to women during their third trimester of pregnancy. A maternofetal hemorrhage can occur during bleeding episodes. In theory, a bleeding episode at any point in pregnancy puts women at risk for exposure to and immunization against Rh proteins. However, the need for RhoGAM during the first trimester is unclear, as overall blood volumes are low, and there is minimal data supporting its use. Many providers administer a smaller dose of immunoglobulin (marketed as MICRhoGAM and containing 50 mcg) to women in the United States who experience bleeding episodes in the first trimester. Despite the lack of evidence in its support, administration of RhoGAM and MICRhoGAM is safe, with no reported adverse effects. There continues to be controversy in organizations including ACOG about the use of Rh immunoglobulin after bleeding episodes in the first trimester despite at least 40 years of research and debate. The big picture: The use of RhoGAM after first-trimester miscarriage or abortion is controversial and the standard of care in your community and cost should be considered. Despite the lack of medical evidence to its benefit, RhoGAM confers minimal risk. In low-resource settings where Rh testing or use of RhoGAM is difficult, Rh unknown or negative status of a woman in the first trimester should not interfere with her ability to receive an abortion, as the risk to future pregnancies has not been documented.
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Counseling for Miscarriage Management
Miscarriage is often an emotionally charged event in a woman’s life. A woman diagnosed with early pregnancy loss or incomplete miscarriage has several treatment options, all proven safe and effective. She can choose expectant care, medication management with misoprostol, or uterine aspiration. A shared decision-making approach is useful for preference-sensitive decisions, like miscarriage management. Patient-centered counseling allows women to decide on the treatment option that best suits them.
After the diagnosis has been established, begin by discussing the following relevant information:
- Her diagnosis
- Details and success rates of each management method
- Any pertinent medical conditions that may affect her management
Next elicit from the patient her priorities for management:
- Does she prefer a more natural experience by passing the pregnancy at home? Does she desire a rapid resolution?
- What are her feelings about pain, bleeding, seeing pregnancy tissue, or having anesthesia during a procedure?
- Are family and work responsibilities, or experiences with prior miscarriages or abortions important factors?
Using a checklist of common priorities may be a useful decision aid for this discussion. As the clinician, your role is to translate how those priorities relate to each of the available management options.
After exchanging information regarding both the medical facts and her personal priorities, together you and the patient can reach a decision for how to manage her miscarriage. This decision should reflect her priorities and preferences. A woman who chooses expectant management may want to have misoprostol on hand, so that she can shift her approach later without having to return to the office. It is always important to provide a point of contact and definitive follow-up for women during the miscarriage process, and be able to make referrals for supportive counseling when needed.
Resources
Patient Treatment Priorities for Miscarriage (Counseling Decision Tool).
Video-based Modules — Counseling for EPL Management Options.
Video Lecture — Managing Early Pregnancy Loss: A Preference-Sensitive Decision.
Miscarriage Treatment Options — Patient education handout
Patient Aftercare Instructions for all treatment options
Miscarriage Counseling Resources
Sources
Wallace RR, Goodman S, Freedman LR, Dalton VK, Harris LH. Counseling women with early pregnancy failure: utilizing evidence, preserving preference. Patient Educ Couns. 2010 Dec;81(3):454-61.
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Insights into abortion and miscarriage care is a publication of the Reproductive Health Access Project and Innovating Education in Reproductive Health, a project of the Bixby Center for Global Reproductive Health, UCSF.
© 2015 Reproductive Health Access Project and Innovating Education in Reproductive Health.
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Teaching Pain Management for Uterine Aspiration
In caring for patients undergoing a uterine aspiration procedure, there are a number of techniques a clinicians can practice to reduce patient pain and discomfort. For many, simple non-pharmacological steps can be taken before the procedure to reduce anxiety and subsequent experience of pain. These steps include:
- Giving patients an opportunity to ask questions
- Addressing any concerns a patient may express about the procedure
- Assuring the person that abortion is a very safe an common procedure, and
- Promoting a culture of dignity and respect in your office setting
During the procedure, there are a variety of pharmacologic agents that can be used to reduce pain. Understanding the aspects of pain management for uterine aspiration is key component of providing patient centered care. It’s important for learners to understand that patients should be counseled to explore which paint management regiment will make them comfortable during their procedure.
What is Pain?
Pain is a complex interaction of sensory signals, emotional state and the cognitive evaluation of the cause and significance of the stimuli.[Melzack & AMA]
Even brief periods of intense pain may have long-term consequences for women, including difficulty with future gynecological exams, pelvic pain or psychological issues Evidence shows that significant pain is not rare from a standard pelvic exam and is most correlated with a negative emotional reaction to the clinician.
Key Teaching Points
- Multimodal pain control includes:
- Non-pharmacologic strategies – strongly recommended for all women
- Systemic medications – NSAIDs and IV moderate sedation reduce pain. Individualized oral medications may improve experience and comfort.
- Local medication – strongly recommended for all women
Uterine aspiration for undesired pregnancy or miscarriage affects all three levels in many, ways, so a multimodal approach to comfort is especially useful. [Hilden 2003] Many studies of pain with uterine aspiration find mean pain scores of 5-7/10 with varying types of anesthesia. Clinicians consistently underestimate patient pain[Singh 2008] so careful attention to local anesthesia, individualization of care on all three levels, and/or moderate-dose IV sedation can reduce pain. General anesthesia increases risk and expense and is not recommended for routine procedures. Asking for pain scores after a procedure provides education for the clinician as well as information for clinical care.
Non-pharmacologic interventions
Evidenced-based non-pharmacologic strategies that improve comfort for the patient include: establishing relationship and rapport with a patient; preparation leading to a higher level of understanding; participation in the choice of anesthesia; relaxing atmosphere including ambient music (though not via headphones); and counseling techniques such as positive suggestion and diversion of attention.
Physical non-pharmacologic interventions include lower abdominal heat; moving slowly without abrupt change; and avoiding initial pain from the speculum or anesthetic injections. These elements of care are most critical when women have no or a low level of systemic medication, though are important for pre- and post-procedure comfort for all women.
Systemic medications
NSAID medications help with uterine pain, especially post procedure. Women often have preferences regarding feeling more awake or more relaxed/less aware for uterine aspiration. Groups that choose no systemic medications or IV sedation have similar pain and satisfaction. A study of women in a community abortion clinic found that IV moderate sedation with 100 mcg fentanyl + 2 mg midazolam provided significantly better pain control than oral medication with 10 mg oral oxycodone + 1mg sublingual lorazepam. Studies where all women are given the same dose have not demonstrated benefit of oral benzodiazepines or oral narcotics. If oral medications are used, they should be individualized to the preference and estimated tolerance of the woman.
Local medication significantly improves pain with tenaculum placement, dilation and aspiration when an adequate amount is used, and is critical for uterine aspirations when women are awake. Less than the equivalent of 20 mL of 1% lidocaine is generally inadequate. See the separate blog post entry on this topic for more information.
You can access Dr. Meckstroth’s video lecture and slides on pain management for uterine aspiration.
Karen Meckstroth, MD, MPH, is an Associate Clinical Professor of Obstetrics, Gynecology, and Reproductive Sciences at UCSF. She is also the Director of the UCSF Women’s Options Center at Mount Zion.
A Practical Guide for Establishing a Jail Rotation
Carolyn Sufrin, MD, PhD
A rotation where Ob/Gyn residents care for women in prison and jail can be a transformative experience for residents and provides important services for a vulnerable population of women. The clinical and didactic experience can enhance their communication skills and teach them key aspects of structural competency which are bound to benefit them and their patients well beyond the walls of a jail. The following articles provide a more detailed account of resident responses to the rotation and the broader benefits.
How can other residency programs set up this kind of a rotation?
Step One:
Getting support from within your department to develop a partnership with a nearby jail or prison which houses women, and designating a faculty member to lead the rotation. You will need to work with your residency program director to find a time slot in the resident rotation schedule—ambulatory blocks usually work well. You may have to do some leg work to then get in touch with the medical director at a jail or prison you’ve identified as a possible site; local Sheriff’s and public health departments can be helpful places to look.
Step Two:
The correctional facility and the academic department will need to determine the institution-specific arrangements, such as a memorandum of understanding, malpractice coverage, and salary support for the precepting faculty member.
Step Three:
This faculty member will need to get a sense of what services are currently available for women at the facility and the site-specific details of how clinical services fit into the routine of jail or prison—ideally by working there for at least a few months before having a trainee.
Step Four:
The faculty member will need to figure out how to get temporary security clearance for the resident to enter the facility; we have interns fill out the necessary paperwork during their orientation. The faculty member should then put some thought into the didactic component of the curriculum, including a brief orientation session at the beginning of each resident’s rotation. The following article provides a list of the readings we have residents choose from, and also provides more information about how our rotation is set up. A template for the slide presentation and Caring for Challenging Patients exercise we use at the orientation, as well as a reading guide for instructors can be found here.
Step Five:
Educational grants offered by your institution may help to jump start the process, and faculty members can also work with the jail or prison to procure supplies that might not already be there; having services on-site is more cost effective for the facility than transporting an inmate off-site for specialty ob/gyn care.
Once these key logistical pieces are put into place, the resident can start accompanying the faculty member and the integrated, didactic component can begin.
Dr. Sufrin is an Obstetrician-Gynecologist and a medical anthropologist who has worked on reproductive health issues for incarcerated women for the last seven years. She is currently working on a book, Jailcare: The Safety Net of a U.S. Women’s Jail.
The Importance of Family Planning Training in Zimbabwe: Part Two
During the last week I was in Zimbabwe, I had the opportunity to spend some time at Harare hospital. Harare hospital established a post-abortion care unit over a decade ago, which was meant to be a manual vacuum aspiration (MVA) clinic. MVA is an inexpensive, safe, and easy technique that can be used to perform abortions through the early 2nd trimester, as well as to treat complications of unsafe abortion. In Zimbabwe, abortion is legal but highly restricted. Even in cases of rape, incest, or to save the life of the woman, hospital administration permission must be obtained, and in some cases, court magistrates or the opinions of two independent physicians must be obtained. These restrictions, combined with the extreme poverty, unequal status of women, and lack of access to contraceptives, have led to an epidemic of unsafe abortion in Zimbabwe.
The MVA clinic, or “Room 20” as it’s called there, consists of a large room with 6 beds, which were almost always full throughout my stay. Even more alarming, was the long line of women waiting outside Room 20, which often led down the hallway and around the corner from the clinic. These women typically were suffering from bleeding and/or infection, repercussions of unsafe, illegal abortion. After getting to the clinic, they typically wait several hours to be seen, even before they receive treatment. Many women wait hours or days for their family members to bring the money needed to pay to be seen. Many women waited for the doctor, who was typically covering many other patients at the same time, particularly the busy labor and delivery unit.
I was able to work with a few residents the days that I was in Room 20, teaching them MVA technique. The most memorable patient was one of the first I saw- a woman who came in hemorrhaging and severely anemic. She was somnolent and unable to speak, but her chart indicated she had two children. The resident and I quickly performed the MVA and were able to stop her bleeding, but she needed a blood transfusion urgently. Several days later, due to significant blood shortages, we were still waiting for a blood transfusion.
My trip to Zimbabwe was a humbling experience, as a physician, an American, and as a woman. It was heartbreaking to see patients that needed so little in order to be treated and not be able to treat them. At the end of my trip, I felt that I had accomplished so little of what I’d hoped for, but I did learn one simple and important lesson that will forever be ingrained in me: contraception saves lives. Contraception is safe, cost-effective, and it saves women’s lives.
I am optimistic about Zimbabwe’s future. It has a talented, educated, and dedicated population of physicians, nurses, and other professionals. The residents I worked with wanted to learn more about contraception and wanted to be able to provide a full range of options to their patients. Recently, Dr. Valerie Tagwira, a family planning specialist and faculty at UZ, started training residents regularly in IUD insertion. She’ll soon be joined by another family planning specialist from the United States, Dr. Diane Morof, who I know will continue to be a strong advocate for safe abortion in Zimbabwe.
Abortion should be safe, legal, and accessible everywhere, including Zimbabwe. But until it is, we must train clinicians to insert LARCs, educate women about their contraceptive options, and continue spreading the message that contraception saves women’s lives.
Meredith Warden MD, MPH is a Family Planning Clinical Fellow and an Ob/Gyn at the University of California, San Francisco.
The Importance of Family Planning Training in Zimbabwe: Part One
Recently, I had the opportunity engage in some family planning clinical work in Zimbabwe. Zimbabwe is in southern Africa, and is a country that has a complicated and fascinating history. Zimbabwe once was a prosperous country, known as the “breadbasket of Africa.” Apartheid officially ended in 1980. Shortly after that time, a military leader named Robert Mugabe came into power bringing massive corruption and dysfunction to the country and leading to a historic economic collapse in the 2000’s. Accompanying that economic collapse was a dramatic increase in maternal mortality in Zimbabwe.
Since that time, the country has been on a long, slow road to recovery. It, however, still remains a country divided between a population of well-educated and more prosperous Zimbabweans and a population in devastating poverty. The maternal mortality rates remain very high and are mostly due to hemorrhage, hypertensive diseases of pregnancy, infection and unsafe abortion. And although about 60% of Zimbabweans use “modern” contraception (mostly the pill), IUD use is almost negligible. Lack of access to contraception is a huge reason why the fertility rate is significantly higher among the poorest women in Zimbabwe.
My experience in Zimbabwe began at Parienyatwa Hospital, which used to be a private hospital during apartheid but is now a public hospital for some of Zimbabwe’s poorest populations, similar to Harare Central Hospital, the traditional public hospital of Harare. Many members of the University of Zimbabwe (UZ) faculty have been trained in IUD insertions and regularly perform them in their private practice settings. In the public sector, however, IUDs are far less commonly utilized mostly because of cost, lack of faculty supervision, and misconceptions about the risks of IUDs. Contraception, specifically contraception counseling, is also something that is routinely beyond the realm of physicians’ scope of work (except procedural contraception). Postpartum contraception counseling is done by nurses, rarely physicians. One of my goals was to emphasize how important contraception is to the health of our patients and should be to their doctors.
I brought a bunch of demo IUDs and IUD insertion models with me and started by doing some hands-on training combined with didactics. The residents were fantastic; they were very eager to learn about not just IUDs but also methods that aren’t available in Zimbabwe. We had a journal club where we discussed the evidence (or lack thereof) linking the IUD to infertility. By the end of my time there, I was able to train several residents and one nurse midwife on IUD insertions. I also got to practice insertions and removals of the 2 rod implant available in Zimbabwe, which is similar to the single rod implant we have here in the US. It was fascinating working with the residents; they have excellent clinical skills since they rely on them far more than lab values or imaging. I also recently heard that faculty will now supervise residents in a weekly family planning clinic, specifically to proctor them on IUD insertions. It was an amazing feeling to get to do some actual training by the end of my time in Zimbabwe but even more amazing to know that the UZ residents are going to continue to have access to training.
Meredith Warden MD, MPH is a Family Planning Clinical Fellow and an Ob/Gyn at the University of California, San Francisco.
Where are the Nurses in Abortion Care?
There are no clear guidelines for managing conscientious objection in nursing; not only is it tolerated, but in many institutions, it becomes an unwritten policy. Many nurses who are supportive of reproductive health choices for women know nurses who refuse to care for patients requiring basic nursing care when undergoing termination inductions. Nurses can hide behind the availability of conscientious objection to refuse to participate in abortion care, in spite of the fact that the American Nurses Association Code of Ethics clearly states that:
“The nurse, in all professional relationships, practices with compassion and respect for the inherent dignity, worth, and uniqueness of every individual, unrestricted by considerations of social or economic status, personal attributes, or the nature of health problems.”
As a registered nurse, I am horrified by such a lack of compassion. How will we train the next generation of abortion providers if we don’t teach patient-centered care? Fortunately, there is a growing movement among nurses to include reproductive health care and embrace choice in pre-licensure and advanced practice nursing education, as well as the incorporation of manual vacuum aspiration and medication abortion skills into advanced nurse practice. Nursing Students for Choice (presently called Nursing Students for Sexual and Reproductive Health) is becoming more and more visible on the campuses of the leading nursing schools, and the National Abortion Federation Clinicians for Choice group has recently expanded its membership to include all nurses, not just those in advanced practice.
Hopefully these nascent efforts within nursing will expand to nurses in all settings, not just those who have already committed to caring for women seeking reproductive health care. The importance of the interprofessional health care team is essential to the continued success of the provision of reproductive health care, and nurses are fundamental to teams that meet all dimensions of patient care.
Amy Levi is the Albers Professor of Midwifery at the University of New Mexico College of Nursing. She is a Fellow in the American Academy of Nursing, and a Fellow of the American College of Nurse-Midwives. She serves on the Advisory Board of Clinicians for Choice and Reproductive Options in Education, and is a member of the Board of Directors of the Association of Reproductive Health Practitioners. She is the Chair of the Research Section of the Division of Global Health of the American College of Nurse-Midwives, and serves on the Editorial Boards of the journals Midwifery and Evidence-Based Midwifery.
Notes From a Full Spectrum NurseMidwifery Student, Part II
Guest Post: Holly Carpenter, RN, CNM Candidate, UCSF
Both APC and pre-licensure nursing students still face a fairly bleak picture in terms of standard SRH training and education. In conversations with nursing and medical students at UCSF, I found a shared sentiment of disappointment in this educational gap. Nursing students at all levels are eager for more training and education in sexual and reproductive health – specifically focused on abortion. To meet these demands, a first year medical student and I designed a noontime interprofessional elective entitled “Family Planning and Reproductive Choice”, to which we invited guest speakers who covered a wide range of SRH-related topics, including:
- options counseling
- adoption
- values clarification
- IUD insertion
- clinical aspects of abortion with a papaya workshop (www.papayaworkshop.org)
- public health aspects of abortion
- the personal experience of abortion hosted by Exhale (After Abortion Talkline)
Student reception was overwhelmingly positive, and we had packed classrooms throughout the quarter. Over the next few months, it became clear that nursing students from around the country are clamoring for this training. In collaboration with an incredible, interdisciplinary group of nursing educators and innovators, I’m currently in the process of creating and disseminated the elective as a nationally applicable curriculum. We are planning to implement the first pilots at Oregon Health and Sciences University, Yale University, the University of New Mexico, and the University of Pennsylvania, among others.
The elective materials and curricular resources will be added to the Nursing Students for Sexual and Reproductive Health (formerly Nursing Students for Choice) website. Through the efforts of dedicated grassroots nursing student activists at these campuses, we hope to demonstrate to faculty and administrators that we strongly believe this content needs to be included in our standard curriculum, not just to satisfy our own interests, but to prepare us to be competitive entrants to the nursing workforce, provide access to high quality sexual and reproductive health care to our patients, and normalize abortion care within the full spectrum of nursing scope of practice.
Notes From a Full Spectrum NurseMidwifery Student, Part I
Guest Post: Holly Carpenter, RN, CNM Candidate, UCSF
When I was choosing between various CNM (certified nurse midwifery) Master’s programs in 2010, the faculty biographies at UCSF were the deciding factor. Every CNM on faculty was described as “Full Spectrum”, meaning they cared for patients through every reproductive health outcome, including abortion. My initial interpretation of this term was, “Wonderful! These midwives are providing abortions, and that means that I’ll be taught how to provide abortions.”
As it turns out, while some UCSF CNM faculty provide medication abortions and place laminaria, CNMs in California do not typically perform first-trimester surgical abortions or manual uterine aspiration procedures (MUAs). This situation is not unique to California; CNMs and other advanced practice clinicians (APCs) are permitted to provide MUAs in only four states: Vermont, New Hampshire, Montana, and Oregon (Weitz et al, 2013). While the skills involved in first-trimester MUAs are identical to those used in “miscarriage management” – a procedure that is legally within the APC scope of practice – many states have explicitly banned APCs from providing MUAs. Obviously, anti-choice politics play a major role in these bans, as evidenced by the recent rash of APCs-as-provider bans that have gone forward during this most recent period of abortion restricting legislation. The impact of these bans is substantial, and connecting the dots is not difficult:
- Abortion is one of the most commonly performed procedure for women (Boonstra, Benson Gold, Richards, & Finer, 2006)
- “As primary care providers APCs are an obvious entry point to the health care system for women facing unintended pregnancies”(APC toolkit)
- In 2004, APCs saw six times as many women for publicly funded family planning services as did physicians (Frost & Frohwirth, 2005).
- Under the affordable care act, the proportion of the US population receiving primary care from APCs is expected to increase substantially (NPs, CNMs, and PAs offer a competent source of women’s primary care and often practice in medically underserved settings – Institute of Medicine Committee on the Future of Primary Care & Donaldson, 1996).
- Limiting access to abortion is harmful to women (Lang, 2013)
- Therefore, the logical conclusion: banning the most accessible providers from performing a commonly demanded procedure is going to have a negative impact on medically underserved women.
However, progress is being made. In California, the Health Worker Pilot Program has been training APCs as first-trimester MUA providers under a legal waiver from the CA State Legislature since 2005. The results of this project have been studied and published, and they offer proof that APCs are equal to MDs in safety, efficacy, and patient satisfaction (Weitz et al, 2013). What was clear to me in 2010 is becoming clear to the rest of the state through this project, and APCs in California are poised to address the gap in services that MD-only provider laws create. (Weitz et al, 2013).
We still face several major hurdles in terms of training and education. A 2005 survey of APC programs demonstrated that only 53% of schools in the US offer didactic instruction in medication or aspiration abortion, and a mere 21% offer clinical training in these procedures (Foster et al, 2005). Even at UCSF, where CNMs are taught to provide comprehensive options counseling (two hours of instruction), contraceptive methods (one quarter of a pharmacology-focused class), and medication abortions (one hour of instruction), we are not taught how to provide first-trimester MUAs. In conversations with other UCSF nursing and medical students, I found that my sentiment of disappointment was shared, and that students were eager for more training and education in sexual and reproductive health – specifically focused on abortion.
In the next blog post in this series, I’ll describe my review of the currently available curricular resources and our initial effort to bring more RH teaching into the curriculum at UCSF. I’ll also discuss my current collaboration with an incredible group of nursing educators and innovators in the creation of a nationally applicable curriculum, and our plans to disseminate it through Nursing Students for Choice and pilots at UCSF, Oregon Health and Sciences University, Yale University, San Francisco State University, the University of New Mexico, and other schools of nursing. Please direct your feedback and comments to info@repro.dev.cshp.co.
References:
http://www.guttmacher.org/presentations/abort_slides.pdf
http://www.nytimes.com/2013/06/16/magazine/study-women-denied-abortions.html?pagewanted=6&_r=0