Abortion

Question 1

over 80% of abortions in scotland are what?

Answer 1

medical abortions

Question 2

over 70% of abortions happen when?

Answer 2

under 9 weeks

earlier gestations = safer procedure

increasing gestation = marker poor access

Question 3

in soctland is late abortion offered (>20 weeks)

Answer 3

no

Question 4

are most women sure about thier decision?

Answer 4

yes

>90% are certain about their decision

it is most difficult for the women that are unsure on their decision

Question 5

important to ensure women have ______ if needed

Answer 5

support

friends/family

formal counselling

Question 6

how is medical abortion carried out?

Answer 6

1. mifepristone p.o. (200mg) stat (taken in clinic)
2. 24-48 hours later Misoprostol (800 mcg) vaginal/sublingual/buccal
3. misoprostol can be repeated every 3 hours

Question 7

can you do medical abortion at home?

Answer 7

yes

under 10 weeks

mifepristone in clinic then Misoprostol at home

Question 8

is abortion safe?

Answer 8

yes but it is painful and causes heavy bleeding

home allows for more privacy, involvement of partner/friend, own food/entertainment, better pain management e.g. bath etc, subjective patient control, ‘can i jus thave the pill’

but risks = heavy bleeding (need for another adult), incomplete procedure (need for follow up pregnancy test), GI upset common

Question 9

what are the sifferent ypes of surgical abortion?

Answer 9

dilation and evacuation

suciton abortion (STOP)

manual vacuum aspiration (MVA)

Question 10

what are points for local versus general anaesthesia?

Answer 10

LA:

• shorter time in hospital (reduced recovery time)
• painful (but over less time than medical)
• aware of treatment and intimate examination

GA:

• longer recovery time, need someone to collect
• pain free
• have the risks associated with anaesthesia

both:

• less risk retained tissue
• risk of uterine perforation/cervical damage
• shorter post-procedure bleeding
• can fit intrauterine contraception immediatley

Question 11

what is the follow up required?

Answer 11

medical at home: pregnancy test

all abortion treatment must be supported by 24 hour access to advice and emergency admission

Question 12

doctors responsibilities in abortion care: conscientious objection

“no person shall be under any duty , whether by contract or by any statutory or other legal requirement, to participate in any treatment authorised by this act to which he has a conscientious objection”

what does conscientious objection include and not include?

Answer 12

includes:

• limited to medical staff participating in the abortion procedure
• right to opt on providing abortion care on an individual level
• obligation to ensure that the women is still able to access that care

does not include:

• medical or nusing care provided to a women currently undergoiing abortion treatment
• care a pregnant women requires who is considering abortion

Question 13

why do women die form abortion

Answer 13

very safe in our country

unsafe abortion: abortion performed by person lacking skills/environment not comforming to minimum medical standards

Question 14

what is the legislation of the abortion act?

Answer 14

1. 2 doctors must certify in good faith that at least one fo the five clauses apply to the women requesting abortion
2. agree on one clause
3. must have an insight or an understand on the womens individual circumstances
4. unique process across all of medicine in Britain
5. Covers Scotland, England and Wales

Question 15

what are the different legal criteria of the abortion act?

Answer 15

• A the continuance of the pregnancy would involve risk to the life of the pregnant woman greater than if the pregnancy were terminated;
• B the termination is necessary to prevent grave permanent injury to the physical or mental health of the pregnant woman;
• C the pregnancy has NOT exceeded its 24th week and that the continuance of the pregnancy would involve risk, greater than if the pregnancy were terminated, of injury to the physical or mental health of the pregnant woman;
• D the pregnancy has NOT exceeded its 24th week and that the continuance of the pregnancy would involve risk, greater than if the pregnancy were terminated, of injury to the physical or mental health of any existing child(ren) of the family of the pregnant woman;
• E there is a substantial risk that if the child were born it would suffer from such physical or mental abnormalities as to be seriously handicapped

Question 16

what are the differences between the UK and NI?

Answer 16

NI is 28 wekks where as the UK is 24 weeks

in the UK the doctor decides if a women fits the criteria of abortion but in NI it is the womens choice

Question 17

abortion is a highly ________ issue

Answer 17

contensious

aguments for: rights of the women to health and life and to make choices about her body and reproduction

Question 18

the solution may be __________

Answer 18

contraception

Question 19

True or False:

1/3 of women in UK have an abortion

Answer 19

true

Question 20

True or False:

about half of teenagers that become pregnant end the pregnancy by abortion?

Answer 20

true

Question 21

True or False:

if a womens partner or family dont want her to have an abortion then she cant have one

Answer 21

false

always womens choice and they can change their mind right up until the abortion

Question 22

True or False:

if an under 16 has an abortion, her parents/carers will be told

Answer 22

false

if they are mature enought to understand what is happening, doctors will not tell parents or carers

Question 23

True or False:

abortion is banned by all religions

Answer 23

false

Question 24

True or False:

giving birth is safer than having an abortion?

Answer 24

false

Question 25

True or False:

abortion causes depression and infertility

Answer 25

flase

women more likely to feel depressed if they are forced into a situation they dont want

abortion does not cause infertility

Question 26

True or False:

Abortion is free on the NHS in Scotland, England and Wales?

Answer 26

True

Question 27

True or False:

your GP will be told if you have an abortion?

Answer 27

false

you can refer yourself to an abortion clinic if you dont wnat to tell them

Question 28

True or False:

a pregnancy test one week after sex will tell you if you are pregnant or not?

Answer 28

false

a pregnancy test may not be accurate until you have missed a period or 3 weeks after unprotected sex

Question 29

Case 1:

• May is a 19 year old university student and has been having sex with her boyfriend for around 6 months. They usually use condoms for contraception but they sometimes forget. Her menstrual cycle is regular, every 28-30days, and her last period was 6 weeks ago. Two days ago she did a home pregnancy test which was positive. She goes to see her GP and is upset and says she doesn’t know what to do, but she doesn’t think she can go through with the pregnancy as she is still at university and feels too young to have a baby.
• If she wishes to have an abortion, what legal criteria must be met?
• What human rights are relevant to this case and why?
• How might ethical concepts (such as autonomy, beneficience, nonmalefiance etc.) be relevant to this case?

Answer 29

Legal Criteria:

Legal status:

• A the continuance of the pregnancy would involve risk to the life of the pregnant woman greater than if the pregnancy were terminated;
• B the termination is necessary to prevent grave permanent injury to the physical or mental health of the pregnant woman;

•C the pregnancy has NOT exceeded its 24th week and that the continuance of the pregnancy would involve risk, greater than if the pregnancy were terminated, of injury to the physical or mental health of the pregnant woman;

• D the pregnancy has NOT exceeded its 24th week and that the continuance of the pregnancy would involve risk, greater than if the pregnancy were terminated, of injury to the physical or mental health of any existing child(ren) of the family of the pregnant woman;
• E there is a substantial risk that if the child were born it would suffer from such physical or mental abnormalities as to be seriously handicapped.

Human rights/ethics:

• Human rights around abortion are often caught up in the woman’s rights versus the fetus’ future rights
• Right to autonomy – ethically patient should make her own decision about treatment, legally that decision is made by a doctor
• Beneficience and nonmalefiance – important she is given support and the ability to make her decision and options to safe options for abortion

Question 30

Case 2:

• April is 15 years old and has been having sex with her boyfriend for around 6 months. They usually use condoms for contraception but they sometimes forget. Her menstrual cycle is regular, every 28-30days, and her last period was 6 weeks ago. Two days ago she did a home pregnancy test which was positive. She goes to see her GP and is upset and says she doesn’t know what to do, but she doesn’t think she can go through with the pregnancy as she is still at school and feels too young to have a baby.
• What ethical and legal issues are important in this case considering her age?
• What other questions are important in this girls history?
• What framework can you use to assess her competency?

Answer 30

Ethical /legal issues and age:

• Can she consent to sexual intercourse? Legally – sex under 16 is unlawful, but 13-15 year olds who are having consensual sex with someone of a similar age are generally not prosecuted as would be more harmful to do so
• Does she have capacity to consent to treatment?
• Is she at risk of exploitation?
• What other questions are important in this girls history? - How old is her boyfriend, was she being forced / coerced into sex, who has she talked to about the pregnancy, what support does she have at home / school

Question 31

What is the Framework to assess competency to consent to treatment - Fraser Guidelines, Gillick Competence?

Answer 31

Lord Fraser stated that a doctor could proceed to give contraceptive advice and treatment to a girl under 16:

“provided he is satisfied on the following matters:

• that the girl (although under the age of 16 years of age) will understand his advice;
• that he cannot persuade her to inform her parents or to allow him to inform the parents that she is seeking contraceptive advice;
• That she is very likely to continue having sexual intercourse with or without contraceptive treatment;
• That unless she receives contraceptive advice or treatment her physical or mental health or both are likely to suffer;
• that her best interests require him to give her contraceptive advice, treatment or both without the parental consent.” (Gillick v West Norfolk, 1985)

Question 32

Case 3:

• May is a 19 year old university student and has been having sex with her boyfriend for around 6 months. They usually use condoms for contraception but they sometimes forget. Her menstrual cycle is regular, every 28-30days, and her last period was 7 weeks ago. She has been referred to clinic from her GP as she has decided that she would wishes to undergo a termination of pregnancy as she is still at university and feels too young to have a baby. You perform an ultrasound and it confirms an intrauterine pregnancy of 7 weeks gestation.
• What different options for abortion treatment are available to her?
• What are the pros and cons of these methods?

Answer 32

Abortion options - pros and cons of different methods:

Medical:

• Early medical termination of pregnancy at home/Medical medical termination of pregnancy
• Home allows for more privacy, involvement of partner/friend, own food/entertainment, better pain management eg bath etc., subjective patient control, ‘can I just have the pill’
• But risks = heavy bleeding (need for another adult), incomplete procedure (need for follow up pregnancy test), GI upset common

Surgical:

• Surgical termination of pregnancy under general anaesthetic / Manual Vacuum Aspiration under local anaesthetic
• Less risk retained tissue, Shorter post – procedure bleeding, Can fit intrauterine contraception immediately. LA – shorter recovery time. GA – pain free
• Risks: uterine perforation / cervical damage

Question 33

Case 4:

• May is a 19 year old university student who underwent an early medical abortion at home at 7 weeks gestation. She took mifepristone 2 days previously and today took misoprostol 6 hours ago. Since then she has been bleeding and is worried that it seems very heavy with large clots. She is experiencing abdominal cramps and feels slightly lightheaded. She called the gynaecology ward for advice and they advised her to attend hospital. When she attends hospital, you assess her a the FY1 on the ward. You are concerned about her and call your senior, who refuses to see her as they have a conscientious objection to abortions.
• What are the legal issues around conscientious objection?
• If a doctor has a conscientious objection to abortion – what should they do if seeing a patient requesting abortion?
• Can this doctor refuse to see this patient?

Answer 33

• This doctor should not refuse to see this patient as this is not partaking in abortion treatment, but rather acute medical care
• GMC guidance re: conscientious objection:

You must explain to patients if you have a conscientious objection to a particular procedure. You must tell them about their right to see another doctor and make sure they have enough information to exercise that right. In providing this information you must not imply or express disapproval of the patient’s lifestyle, choices or beliefs. If it is not practical for a patient to arrange to see another doctor, you must make sure that arrangements are made for another suitably qualified colleague to take over your role

Question 34

Case 5:

• May is a 19 year old university student and has been having sex with her boyfriend for around 6 months. They usually use condoms for contraception but they sometimes forget. She is seen in clinic after a positive pregnancy test and a ultrasound scan confirms her to be 7 weeks gestation. She chooses to undergo early medical abortion at home. You decide to discuss contraceptive options with her as she is clear she does not wanting to be starting a family soon. However, she says she’s not interested as they will be more careful next time.
• What contraception options are available to her?
• Do you think she should use contraception and if so how would you address this?
• What ethical concepts (such as autonomy, beneficience, nonmalefiance etc.) might be relevant to this discussion around contraception?

Answer 34

Good websites for further information about contraception

Ethical issues and contraception:

• Autonomy – important women able to make own decisions about which contraceptive method is best for them (even if you think they might be better suited to, for example, a more effective option)
• Beneficience and nonmalefiance – important she is given support and the ability to make her decision and that you have taken a good medical history as some options may not be medically safe for her. E.g. she should avoid combined hormonal contraception is she suffers from migraines with aura