Termination of pregnancy

  • A primary principle in termination of pregnancy care is to ensure that a woman should always be given as much information as possible about available options, and the opportunity to discuss the risks and benefits as well as the emotional, psychological and social issues of continuing or not continuing her pregnancy

What nurses cannot do within the current legislation

  • The current legislation clearly sets out what nurses cannot do:
    • sign the regulatory forms (HSA1 and HSA4)
    • prescribe abortifacient drugs for use in medical termination of pregnancy
    • provide a termination of pregnancy service alone without a doctor remaining responsible for the woman
    • perform surgical termination of pregnancy
  • The penalties for any person failing to follow the provisions of the Abortion Act are criminal
  • As with any form of health care treatment or procedure, women undergoing a termination of pregnancy procedure should first sign a written consent form. To ensure informed decision making, the consent process should include details of:
    • the process and the procedure to be undertaken
    • the benefits and risks of the range of methods available
    • the potential complications that may occur as a result of the procedure, as well as any other procedures that might need to be undertaken as a result of complications occurring
    • The competence of a woman to consent to the procedure should also be assessed:
    • does the woman demonstrate a reasonable capacity to make a choice about her requested course of action?
    • can she articulate the risks, benefits and alternatives discussed with her?
    • does she understand that her informed decision making must be voluntary?
    • does she understand that her consent can be withdrawn at any time?

Confidentiality

  • All women (including those under 18 years of age) seeking a termination of pregnancy have a right to confidentiality from all health care staff. Only in exceptional circumstances (for example, where the health, welfare or safety of the woman, a minor or other person is at risk) should a third party be informed where the woman refuses to give her consent to disclosure

Service provision and practice considerations

Access and referral

  • All women in England, Wales and Scotland can access a termination of pregnancy if two doctors determine in good faith that their circumstances meet the terms of the Abortion Act 1967 (as amended by the Human Fertilisation and Embryology Act 1990). However, as mentioned above, in exceptional circumstances the Act allows that only one doctor may initiate treatment. Termination services should therefore be easily accessible and should allow both direct referrals as well as referrals from health professionals. Providers of termination services should be committed to ensuring that women can access services as early as possible to reduce the possibility of associated health risks

Pregnancy options

  • A wide range of health professionals and organisations currently provide help and support with the decision-making process. Systems should be in place to rapidly refer women for pregnancy options, discussion and/or counselling when required

Pre-assessment—the nursing role

  • Registered nurses who are appropriately trained and assessed as competent in line with local guidance or protocols may undertake pre-termination of pregnancy assessment (ensuring that it is two doctors who agree that the termination of pregnancy is justified under the grounds of the Abortion Act 1967)
  • It is important to see the woman (regardless of her age) on her own at some point to allow her to give accurate answers and freely express her thoughts and feelings
  • The role of pre-termination assessment is holistic, multi-faceted and should include:
    • developing an understanding of the circumstances leading to a woman requesting a termination and offering options, discussion and/or counselling
    • a medical and physical assessment, in line with recommendations from the RCOG guidelines, including estimation of gestational age
    • referral for medical assessment as appropriate
    • a review and explanation of all methods and available services (these may be dependent on gestational age and local policy), which should include the risk of potential complications (including local risk percentages); written information should be available and accessible
    • consent for the chosen procedure, including assessment of competence to consent in the case of a child under 16 years of age
    • an assessment and discussion of future contraceptive needs to include all available methods, and promotion of the commencement of contraception at the time of a termination of pregnancy or immediately afterwards
    • STI testing, treatment, partner notification
    • appropriate and speedy referral to other agencies as appropriate
    • ensuring that medical assessment has been completed
    • ensuring that the HSA1 form (and drugs prescribed) has been signed by a medical practitioner and before any treatment is commenced
    • maintaining accurate records of all care provided
    • clearly setting out women’s rights relating to their own sexual and reproductive health—as well as their general health

Post-termination of pregnancy care

General advice and support

  • General advice and support after a termination of pregnancy is aimed at enabling a healthy recovery, minimising risk, and initiating early intervention or treatment if indicated. Each woman should be given an information leaflet and a 24-hour contact telephone number. Routine follow up after surgical or medical termination where successful completion has been confirmed is not clinically necessary. Where successful completion has not been confirmed women should be offered a follow up appointment to rule out a continuing pregnancy
  • Contraception should be discussed and supplied as appropriate. Termination of pregnancy providers should be promoting the benefits of long-acting reversible contraceptives (LARCs) and should have access to fit or provide a full range of contraceptive methods including a LARC, or have clear and timely pathways to refer for these methods

General aftercare advice

  • Vaginal bleeding (with or without clots) can last for up to 2 weeks after a surgical procedure and longer after a medical procedure. The bleeding should decrease in amount over these weeks. Should the woman experience continuous and heavy bleeding (for example, soaking two or more sanitary pads for 2 consecutive hours) she should contact the service provider or seek medical attention urgently
  • Sanitary towels should be used instead of tampons during this post-treatment bleeding to limit the risk of infection
  • Over the counter analgesia such as paracetamol and/or ibuprofen can be used to relieve any abdominal pain or cramping. Hot pads or hot water bottles might also afford some relief
  • The woman should be advised who to contact if she experiences lasting pain, signs of fever, malaise, offensive vaginal discharge, abdominal tenderness, continuing signs of pregnancy or other unusual signs or symptoms
  • Breast discomfort can persist for seven to 10 days and a well supporting bra and analgesia can provide some relief. Some women can lactate. They should be advised not to express the milk, which stimulates further production
  • Normal activities can be resumed when the woman feels able
  • After a termination most women feel relieved but some may also feel emotional distress, such as sadness or guilt. Women should be advised how to access counselling and support should they need it
  • Pregnancy-related symptoms of nausea, vomiting and tiredness usually stop within 3 days of a termination
  • It is recommended that sexual intercourse is avoided for a week after the procedure. Condoms should be recommended when sexual intercourse is resumed. In addition, the woman should be advised that fertility can return almost immediately (a woman may ovulate as soon as 10 days post-termination), so reliable contraception should be initiated immediately in the absence of abstinence to avoid a further pregnancy. Women should be advised of all available methods of contraception, including long-acting reversible contraceptives
  • Women should also be advised that high-sensitivity urine pregnancy tests may remain positive for up to 6 weeks post-termination
  • Women who intend to travel long distances or take a flight soon after their termination should be advised to ensure that they have appropriate sanitary wear, remain well hydrated and if appropriate follow standard in-flight guidance regarding exercises
  • The next menstrual period will begin 4 to 6 weeks after treatment. If the woman has not had a period 6 weeks post-treatment, she should do a pregnancy test or contact the service provider

Anti-D and rhesus prophylaxis

  • Anti-D IgG should be given intramuscularly to all non-sensitised RhD negative women within 72 hours following termination, whether by surgical or medical methods

Vulnerable groups and special considerations

  • Special consideration should be given to individuals and groups of women who may be considered to be particularly vulnerable, either physically, psychologically, socially or economically. These considerations include: 
    • safeguarding children
    • language issues
    • female genital mutilation
    • physical disabilities, learning disabilities and mental illness
    • rape and sexual assault
    • domestic abuse
    • forced marriages
    • difficulties with vaginal examinations
    • human trafficking/modern slavery

Conclusion

  • It is important that nurses understand the complexity of decision making around a woman’s decision to terminate her pregnancy. It is equally important to consider the requirements and needs of the wider family or social group, if a woman wishes
  • Nurses working in this specialist area should have access to appropriate continuing professional development to enable them to provide high-quality, evidence-based care. Nursing care in this arena of practice also provides opportunities for nurses to develop new skills, for example ultrasound scanning. The need for more nurse-led research into related topics to extend the evidence base for care should be encouraged

Please refer to the full guideline for recommendations on:

  • Legal considerations
  • Professional development, nurse-led services and support
  • Pregnancy termination methods
  • Specialised service considerations

full guideline available from…

www.rcn.org.uk/professional-development/publications/pub-005957

Royal College of Nursing. Termination of Pregnancy. An RCN nursing framework. August 2017.

First included: July 2018.