Woman-Centered Abortion Care l a u n a M e c n e r e f Alyson G.Hyman,MPH e Laura Castleman,MPH,MD R Ipas works globally to increase women’s ability to exercise their sexual and reproductive rights and to reduce abor- tion-related deaths and injuries. We seek to expand the availability, quality and sustainability of abortion and related reproductive-health services, as well as to improve the enabling environment. Ipas believes that no woman should have to risk her life or health because she lacks safe reproductive-health choices. ISBN: 1-882220-87-0 © 2005 Ipas. Produced in the United States of America. Suggested Citation: Hyman, Alyson G. and Laura Castleman. 2005. Woman-centered abortion care: Reference manual. Chapel Hill, NC, Ipas. Editors: Marty Michaels, Jill Molloy, Kezia Scales Illustrations: Stephen C. Edgerton Cover Design and Layout: Valerie Holbert Glossary: Evangeline Christie and Karah Fazekas Printed on recycled paper. The illustrations and photographs used in this publication are for illustrative purposes only. No similarity to any actual person, living or dead, is intended. Ipas Woman-Centered Abortion Care:Reference Manual Woman-Centered Abortion Care: Reference Manual Acknowledgments This manual was based in large part on the 2004 Ipas curriculum Woman- Centered Postabortion Care: Reference Manual byJeannine Herrick, Katherine Turner, Teresa McInerney and Laura Castleman. The authors are deeply grateful to these colleagues for laying the groundwork for this reference manual. We also want to especially thank: Joan Healyfor her extensive technical guidance and review; Marty Jarrell for her unending patience as we made revisions to reflect scientific changes that occurred during the writing of this manual; and Karah Fazekas for her tireless logistical and editorial work. The authors are grateful to Sally Girvin for her technical assistance on the Medication Abortionmodule and Jill Molloy for her technical assistance on the Reproductive Rightsmodule. This manual has been greatly strengthened by the support and contributions of our partner organizations. Specifically, we thank the following individuals for their reviews and comments: • Jean Ahlborg, MD, EngenderHealth • Marianne Parry, MD, Marie Stopes International • Lorelei Goodyear, Allison Bingham and Michelle Folsom, PATH • Ann Gerhardt, National Abortion Federation In addition, we are grateful for the field experience and technical expertise contributed by the following Ipas staff and consultants: • Traci Baird • Sangeeta Batra, MD • Maria de Bruyn • Amy Entwistle • Rivka Gordon • Leila Hessini • Ann Leonard • Teresa McInerney • Philip Mwalali, MD • Charlotte Hord Smith • Karen Trueman • Judith Winkler i Ipas Woman-Centered Abortion Care:Reference Manual About Ipas Ipas is dedicated to the belief that every woman has a basic right to reproductive- and sexual-health care and to make her own reproductive and sexual choices. We work globally to increase access to high-quality reproductive- health care and to improve women’s ability to exercise their reproductive rights, especially their right to safe, legal abortion. We concentrate on preventing unsafe abortion, improving treatment of its complications and reducing its consequences. We strive for women’s empowerment by increasing access to services that enhance their reproductive and sexual health. The International Conference on Population and Development (ICPD) and its five- year review (ICPD+5) provided a clear mandate to all signatory governments: make abortion care safe and accessible to women in their communities. Ipas is dedicated to scaling up safe abortion services globally and to the full extent of local laws through training, service-delivery improvement, advocacy, research and provision of reproductive-health technologies. Scaling upis defined as achieving universal access to high-quality, sustainable abortion-care services. •Achieving universal access ensures that wherever a woman seeks help when she has unprotected sex, unwanted sex or an unwanted pregnancy, she will find the care she needs, whether it be information, referral, or clinical or related services. Universal access to abortion requires that every public and private facility in a country's health system is trained and equipped and has other measures in place to ensure women’s access to abortion-related care. •Achieving sustainability in abortion-care services requires political leadership, policy development, financial resources and an adequate health-system infrastructurewith trained health-careproviders. ii Ipas Woman-Centered Abortion Care:Reference Manual About This Manual The primary purpose of this reference manual is to provide guidance to health- care personnel on improving the quality of care available to women seeking abortion services. This manual introduces the Ipas MVA Plus®and Ipas EasyGrip® cannulae, and explains the manual vacuum aspiration (MVA) abortion procedure in detail. It also explains medication-abortion methods that use the medications misoprostol and mifepristone. All the methods described here offer women safe, effective options for first-trimester uterine evacuation. Although this reference manual provides extensive information on abortion-care provision, it is not intended to serve as a self-guided learning tool. It is designed to be used as a participant’s manual during trainer-facilitated individualized and group-based courses that include simulated practice and clinical practice with clients under the supervision of an experienced provider; as a learner’s resource to help refresh and strengthen participants’ skills after completion of a course; and as a reference document for those seeking up-to-date information on comprehensive abortion care. Health-care providers planning to conduct courses on abortion care should obtain the manual’s companion piece, Woman-Centered Abortion Care: Trainer's Manual,which supplies educational materials, trainer's notes and competency- based evaluation tools, and is written to encompass multiple adult-learning styles. The Woman-Centered Abortion Care: Reference Manualis useful to a broad audience, including sexual- and reproductive-health clinicians, trainers, program managers, health educators, social workers, outreach workers and other health- care workers. The 12 modules bring a woman’s-rights perspective to abortion- caretraining and service delivery.The manual is divided into two parts. Section I: High-Quality Abortion Careis intended for a wide range of health-facility workers, including administrative personnel and other non-clinicians. These five modules address quality-of-care issues, including client-provider communication, women's rights to high-quality reproductive-health care, and recommendations for monitoring services and ensuring community linkages. Section II: Clinical Carefor Womenfocuses on technical information and is intended for a clinical audience that deals directly in abortion care, including physicians, nurse midwives, counselors and others. The seven modules in Section IIare in the order in which a woman typically receives care; however, facilities may vary the steps of care according to their own settings and needs. For example, some health-carecenters provide contraceptive services after counseling and prior to the abortion procedure, whereas others provide contraceptive counseling and supplies only after the procedure. This manual provides information on both MVA and medication abortion. Whenever possible, choices in uterine-evacuation methods should be made available to women. It is recommended that the techniques introduced in this manual be included in clinical protocols for abortion-related services at health-care centers and systems. Ipas’straining strategies place equal emphasis on improving the technical quality of abortion care and on the overall quality of care that women receive. This comprehensive approach requires learners to reflect on values, attitudes and iii Ipas Woman-Centered Abortion Care:Reference Manual myths associated with abortion and to focus services on the needs and desires of each woman receiving care. Ipas also recommends Effective Training in Reproductive Health: Course Design and Delivery. Reference Manualand Trainer’s Manual, acurriculum designed to develop core training skills for professionals in various areas of reproductive health, including administration, policy and advocacy. To order these and other Ipas resources, contact Ipas at: P.O. Box 5027 Chapel Hill, NC 27516 USA Telephone: 919-967-7052 Toll free (in the United States): 800-334-8446 Fax: 919-929-7687 Email: [email protected] www.ipas.org iv Ipas Woman-Centered Abortion Care:Reference Manual Woman-Centered Abortion Care: Reference Manual Table of Contents Overview and Guiding Principles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1 1.0 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1 2.0 Key Elements of Woman-Centered Abortion Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1 3.0 Upholding Women’s Rights in an Abortion-Care Setting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4 4.0 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7 Reproductive Rights . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9 1.0 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9 2.0 Reproductive Rights . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9 3.0 Barriers to Legal Abortion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13 4.0 Providers as Advocates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16 5.0 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16 Appendix A: Treaty Monitoring Committees . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .19 Appendix B: Statements From Health Professional Associations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .24 Appendix C: Common Regulatory and Administrative Barriers to Obtaining Safe Abortion . . . . . . . . . . . . . . . . . . . .30 Community Linkages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .31 1.0 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .31 2.0 Community Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .32 3.0 Programmatic Strategies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .33 4.0 Summary ................................................................................36 Appendix A: Potential Audiences and Topics for Information, Education and Communication on Abortion . . . . . . . .38 Uterine Evacuation Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .41 1.0 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .41 2.0 Vacuum Aspiration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .43 3.0 Medication Abortion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .44 4.0 Sharp Curettage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .45 5.0 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .46 Appendix A: Complications Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .51 Monitoring to Improve Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .53 1.0 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .53 2.0 What Is Monitoring and Why Is It Important? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .53 3.0 Keys to Effective Monitoring Systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .54 4.0 Four Steps of Effective Monitoring . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .55 5.0 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .59 Appendix A: Written Consent Form – Interview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .61 Appendix B: Written Consent Form – Observation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .62 Appendix C: Sample Clinical Protocols Checklist for MVA Abortion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .63 Counseling . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .65 1.0 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .65 2.0 What Is Counseling? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .66 3.0 Voluntary Informed Consent . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .66 4.0 Counseling in the Abortion Setting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .67 5.0 Privacy,Confidentiality and Informed Decisionmaking . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .67 6.0 Counselors’ Values, Attitudes and Empathy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .68 7.0 Effective Communication . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .69 v Ipas Woman-Centered Abortion Care:Reference Manual 8.0 Women’s Feelings and Decisions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .71 9.0 Making Referrals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .74 10.0 Closing a Counseling Session . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .75 11.0 Special Populations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .75 12.0 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .76 Appendix A: Additional Special Populations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .79 Contraceptive Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .87 1.0 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .87 2.0 Importance of Contraceptive Counseling and Method Provision After an Abortion . . . . . . . . . . . . . . . . . . . . . .88 3.0 Models of Service Delivery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .88 4.0 Women’s Fertility Goals Following an Abortion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .89 5.0 Rights to Privacy, Confidentiality and Informed Choice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .90 6.0 Involvement of Partners . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .91 7.0 Essential Elements of Contraceptive Counseling . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .91 8.0 Medical Eligibility for Contraceptive Use After an Abortion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .93 9.0 Emergency Contraception . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .95 10.0 Special Contraceptive-Counseling Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .95 11.0 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .96 Appendix A: Individual Factors and Counseling Recommendations and Rationales . . . . . . . . . . . . . . . . . . . . . . . . . .99 Appendix B: Guidelines for Selection of Contraception by Method . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .100 Appendix C: Contraceptive Counseling for Special Populations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .105 Infection Prevention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .111 1.0 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .111 2.0 Infection Transmission . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .111 3.0 Elements of Infection Prevention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .112 4.0 Management of Occupational Exposure .......................................................117 5.0 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .117 Appendix A: Sharps Container . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .119 Appendix B: Mixing Instructions to Produce 0.5% Chlorine Solution . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .120 Clinical Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .121 1.0 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .121 2.0 Client History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .121 3.0 Psychosocial Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .123 4.0 Physical Examination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .124 5.0 LaboratoryTests . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .126 6.0 Ultrasound Exam and Ectopic Pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .127 7.0 Reproductive-Tract Infections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .127 8.0 Special Populations to Consider During Clinical Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .128 9.0 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .128 Appendix A: Provision of Antibiotics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .131 Appendix B: Female Genital Cutting (FGC) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .132 Uterine Evacuation Procedurewith Ipas MVA Plus® ..................................................135 1.0 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .135 2.0 Instrument Features, Care, Use and Processing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .135 3.0 Pain Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .148 4.0 Uterine Evacuation Procedure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .151 5.0 Post-Procedure Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .157 6.0 Follow-Up Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .161 vi Ipas Woman-Centered Abortion Care:Reference Manual Appendix A: Comparison of Ipas Instruments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .169 Appendix B: Methods for Processing Ipas MVA Plus®Aspirator and Ipas EasyGrip®Cannulae . . . . . . . . . . . . . . . .170 Appendix C: Approaches to Pain Management During MVA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .172 Appendix D: Suggested Equipment and Supplies for Uterine Evacuation Procedure with Ipas MVA Plus® .......174 Appendix E: Misosprostol as Cervical Preparation for First-Trimester Abortion Using Vacuum Aspiration . . . . . . .175 Appendix F: Sample Clinical Referral Forms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .177 Appendix G: Discharge Information Sheet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .179 Appendix H: Sample Follow-Up Visit Medical Form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .180 Medication Abortion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .183 1.0 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .183 2.0 Preparation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .184 3.0 Mifepristone Plus Misoprostol Regimens . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .186 4.0 Misoprostol-Alone Regimens . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .190 5.0 Pain Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .190 6.0 Side Effects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .191 7.0 Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .193 8.0 Instructions Prior to Leaving the Clinic and Care Afterwards . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .193 9.0 Follow-Up Visit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .194 10.0 Summary ...............................................................................194 Appendix A: Medication Abortion with Mifepristone and Misoprostol – Questions and Answers . . . . . . . . . . . . . .199 Appendix B: Sample Information Sheet for Mifepristone and Misoprostol Medication Abortion . . . . . . . . . . . . . . .201 Appendix C: Abortion Induction with Misoprostol (Cytotec®)in Pregnancies up to Nine Weeks LMP . . . . . . . . . . .203 Appendix D: Early Medication Abortion with Misoprostol – Questions and Answers . . . . . . . . . . . . . . . . . . . . . . . .206 Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .209 1.0 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .209 2.0 Complications of Vacuum Aspiration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .209 3.0 Complications of Medication Abortion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .212 4.0 Rarer Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .213 5.0 Referral . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .213 6.0 After-Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .214 7.0 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .214 Glossary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .217 vii Notes viii