LESSON PLAN

Name of the student teacher:-Miss Seema Mittal Name of subject:-Obstetrics & gynecology

Unit:-2nd Units Name of topic:-Abortion

Class:-BSc. Nsg 3rd year Group size:-40 student

Date & time:-6-11-09, 2:00 pm Venue:-Class room

Name of supervisor:-Miss Jabila mam (MSc. Nsg.) Previous knowledge of group:-What you know about Abortion?

Method of teaching:-Lecture cum discussion method Audiovisual aids:-Chart, Flash card, Transparency, Pamphlets, PowerPoint,
Blackboard

General objectives:-After the class students able to acquire knowledge about the abortion so that they are able to handle the situation of abortion

Specific objectives:-Today we will able to-

1. describe the etiological factors of the spontaneous abortion 2. describe the mechanism of abortion
3.discuss about the threatened abortion 4. discuss about the inevitable abortion
5..discuss about the complete abortion 6.discuss about the incomplete abortion
7.discuss about the missed abortion 8.discuss about the septic abortion
9.discuss about the recurrent miscarriage 10.discuss about cervical incompetence
11. discuss about the legal abortion 12.discuss about the medical termination of pregnancy
13.describe the types of Abortion according to the treatment 14.discuss about the abortion counseling
15.discuss about the preparation of patient foe abortion 16.explain the procedure of the abortion
17.discuss the care after the procedure 18.discuss the role of the midwives
S Objectives Time Content A.V Aids Teaching Evaluation
NO. &
 Learning
Activity
1. To introduce 1min I am Seema Mittal. I am the student of MSc Nsg 1st year in CIMS CON. Today
myself I will teach you about abortion, its types with management, legal issues
regarding abortion & role of midwives also.
2. T o check the 1min Q1.What you mean by abortion?
previous
Q2. Upto how many weeks abortion is legal?
knowledge
about the
topic
SPONTANEOUS ABORTION
3. To discuss
the 1min DEFINITION:-Abortion is the expulsion or extraction from its mother of an embryo What is
spontaneous or fetus weighing 500 gm or less when it is not capable of independent survival spontaneous
abortion (WHO). abortion?
This 500 gm of fetal development attained approximately at 22
weeks of gestation. The expelled embryo or fetus is called abortus. White board What are the
4. To classify 2min CLASSIFICATION OF ABORTION:- types of
the abortion ABORTION abortion?
Lecture cum
discussion
Spontaneous Induced method

Isolated (Sporadic) Recurrent Legal Illegal (Criminal)

Septic-common

Threatened Inevitable Complete Incomplete Missed Septic

LCD
5. To describe 5min ETIOLOGY:- What are the
the 1. Genetic factor:-Autosomal trisomy e.g. trisomy16, polyploidy- 3 or more main causes of
etiological multiple numbers of haploid number of chromosomes e.g 3n=69. Monosomy abortion?
factors of the constitutes 20% of aborts. Commonest is monosomy X (45X)
spontaneous 2. Endocrine & Metabolic factor:- Lecture cum
abortion a. Luteal phase defect (LPD) result in early miscarriage as implantation & discussion
placentation ar not supported adequately. method
b. Deficient progesterone secretion from corpus luteum or poor endometrial
response to progesterone is the cause.
c. Thyroid abnormalities –hypothyroidism or hyperthyroidism are
associated with increased fetal loss.
d. Diabetes mellitus when poorly controlled causes increased miscarriage.

3. Anatomic factor:-
a. cervical incompetence either congenital or acquired,
b. Congenital malformation of the uterus e.g bicornuate or septate uterus
Causes of fetal loss:-
i.) Reduced intrauterine volume
ii.) Reduced expansible property of the uterus
iii.) Reduced placental vascularity when implanted on the septum
iv.) Increased uterine irritability & contractility
c. Uterine fibroid:-with this vascularity decreased at the implantation site, it
is not only responsible for infertility but also for abortion.
d. Intrauterine adhesion:-interfere with implantation, placentation, & fetal
growth

4. Infection:-Transplacental fetal infection occur with most microorganisms &

cause fetal loss
a. Viral : Rubella, cytomegalo
b. Parasitic: Toxoplasma, Malaria
c. Bacterial: Chlamydia, Brucella
5. Immunological:-
a. Autoimmune Disease:-in this the patient make antibodies against their
own tissue & the placenta, these antibodies cause rejection of early
pregnancy e.g. Anti-nuclear antibodies (ANAs), Antiphospolipid
antibodies, Anticardiolipin antibodies (aCL).
b. Alloimmune disease:-

Paternal antigen which are foreign to the mother invoke the

 protective blocking antibody response

These blocking antibodies prevent maternal immune cells from

recognizing the fetus as a foreign entity

There for fetal allograft containing foreign paternal antigens are not
rejected by the mother

Paternal human leukocyte antigen (HLA) sharing with the mother Lecture cum
leads to diminished fetal maternal immunological interaction discussion
ultimate fetal rejection (Abortion) method

c. Blood group Incompatibility: - Rh incompatibility is a rare cause of

death of the fetus before 28th week. Couple with group ‘A’ husband &
group ‘O’ wife have got higher incidence of abortion.
d. Premature rupture of the membranes:- leads to abortion
e. Environmental factors:-
i) Cigarette smoking- formation of carboxy haemoglobin &
decreased oxygen transfer to the fetus.
ii) Alcohol consumption
iii) X-irradiation & antineoplastic drugs
iv) Contraceptive agents like IUD

6. To describe 2min MECHANISM OF ABORTION:-In early weeks death of the ovum occur first, What is the
the followed by its expulsion. In later weeks, maternal environmental factors are involved mechanism of
mechanism leading to expulsion of fetus which may have signs of life but is too small to survive. abortion?
of abortion 1. Before 8 weeks: The ovum surrounded by villi with the decidual covering is
expelled out intact. Sometimes, the external os fails to dilate so that the entire
mass is accommodated in the dilated cervical canal & is called cervical
abortion.
2. 8-14 weeks: Expulsion of fetus commonly occurs leaving behind the placenta
& the membranes. A part of it may e partially separated with brisk
haemorrhage or remains totally attached to the uterine wall.
3. Beyond 14 weeks: The process of expulsion is similar to that of a “mini
labor”. The fetus is expelled first followed by expulsion of the placenta after a
varying interval.
 THREATENED ABORTION
LCD What is
7. To discuss 2min DEFINITIN:-It is a clinical entity where the process of abortion has started but threatened
about the has not progressed to a state from which recovery is impossible. abortion?
threatened CLINICAL FEATURES:-
abortion 1. Bleeding per vaginam: bleeding is slight red in colour & usually in the late
2nd trimester.
2. Pain:- usually painless but there may be mild backache or dull pain in lower
abdomen. Lecture cum
INVESTIGATIONS:-Routine investigation include- discussion
1. Blood-for haemoglobin, ABO & Rh grouping, anti-D gamma globulin has to method
be given in Rh –ve non immunized women.
2. Urine-for immunological tests of pregnancy is not helpful as the test remains
positive for a variable period even after the fetal death.
3. Ultrasonography:-no cardiac motion of the fetus
4. Serum progesterone value of 25ng/ml or more indicate a viable Phamplets
pregnancy. What is the
TREATMENT:- treatment of
1. The patient should be in bed for few days until bleeding stop threatened
2. Sedation & relief of pain by phenobarbitone 30mg or diazepam 5mg tablet abortion?
twice daily.
3. The patient is advised to preserve the vulval pads & anything expelled out per
vaginum, for inspection
4. Report to the doctor if bleeding is more
5. Routine note of pulse, temperature, & vaginal bleeding
6. During discharge the patient should limit her activities for at least two weeks
& avoid heavy work.
7. Coitus is contraindicated during this period
8. She should be re-examined after one month to assess the growth of the fetus. LCD
8. To discuss 2min INEVITABLE ABORTION What you mean
about the DEFINITION:-it is the clinical type of abortion where the changes have by inevitable
inevitable progressed to a state from where continuation of pregnancy is impossible. abortion?
abortion CLINICAL FEATURES:-
1. Increased vaginal bleeding
2. Pain in the lower abdomen
 3. Internal examination reveals dilated internal os of the cervix through
which the products of conception are felt
MANAGEMENT:-The principles of management are:- What is the
1. To take appropriate measures to look after the general condition of the Lecture cum management of
patient. discussion inevitable
2. To accelerate the process of expulsion method abortion?
3. To maintain strict asepsis as outlined in conduction of labour
General measures:-
1. Excessive bleeding should be promptly controlled by administering
methergin 0.2mg, if the cervix is dilated & the size of the uterus is less
than 12 weeks
2. The shock is corrected by intravenous fluid therapy & blood transfusion
3. Before 12 weeks:-
a. Dilation & evacuation followed by curettage of the uterine cavity
blunt curette under general anesthesia.
b. Alternatively, suction evacuation followed by curettage is done.
4. After 12 weeks:-
a. The uterine contraction are increased by oxytocin drip (10 units in
500ml of normal saline) 40-60 drops per minute.
b. If bleeding is profuse with the cervix closed-evacuation of the uterus
may have to be done by abdominal hysterectomy. LCD
9. To discuss 2min COMPLETE ABORTION
about the DEFINITION: - when the products of conception are expelled en masse, it is called What you mean
complete complete abortion. by complete
abortion CLINICAL FEATURES:- abortion?
1. Abdominal pain
2. Vaginal bleeding become absent
3. Internal examination reveals –
a. uterus is smaller than the period of amenorrhoea.
b. cervical os is closed
c. bleeding is trace
MANAGEMENT:- What is the
1. The effect of blood loss, if any should be treated. management of
2. If there is doubt about the complete expulsion of the product, uterine curettage complete
should be done. abortion?
3. Transvaginal sonography is useful to prevent unnecessary surgical procedure. LCD
10. To discuss 2min INCOMPLETE ABORTION
about the DEFINITION:-when the entire product of conception is not expelled, instead a part Define
incomplete of it is left inside the uterine cavity, it is called incomplete abortion. Lecture cum incomplete
abortion CLINICAL FEATURES:- discussion abortion?
1. Continuation of pain in lower abdomen method
2. Persistence of vaginal bleeding
3. Internal examination reveals-
a. Uterus is smaller than the period of amenorrhea
b. Cervical os admitting tip of finger
c. Varying amount of bleeding
4. On examination, the expelled mass is found incomplete.
MANAGEMENT:-
1. Patient may be in shock due to blood loss, she should be resuscitated before
any active treatment is undertaken.
2. In early abortion dilation & evacuation under general anesthesia is to be done.
3. In late abortion the uterus is evacuated under general anesthesia & the
products are removed by ovum forceps or by blunt curette.
4. In late cases, dilatation & curettage operation is to be done to remove the bits
of tissue left behind.

MISSED ABORTION (SILENT MISCARRIGE)

11. To discuss 2min
about the DEFINITION:-When the fetus is dead & retained inside the uterus for a variable
missed period, it is called missed abortion or silent miscarriage or early fetal demise. Define missed
abortion CLINICAL FEATURES:- LCD abortion?
1. Persistence of brownish vaginal discharge
2. Appearance of pregnancy symptoms
3. Retrogression of breast changes
4. Cessation of uterine growth which in fact become smaller in size.
5. Non audibility of fetal heart sound
6. Cervix feel firm
7. Immunological test for pregnancy become negative
8. Ultrasonography shows absence of fetal movement What is the
MANAGEMENT:- management of
1. When uterus is less than 12 weeks than vaginal evacuation can be carried missed
out without delay. This can be effectively done by slow dilatation of the cervix abortion?
 by laminaria tent followed by dilatation & evacuation of the uterus under
general anesthesia. Lecture cum
2. When uterus is more than 12 weeks than induction is done by the following discussion
methods:- method
a. Oxytocin-to start with 10-20 units of oxytocin in 500 ml of normal saline
at 30 drops per minute.
b. Prostaglandin are most effective than oxytocin in such cases. The
methods used are:
 Prostaglandin E1 analogue (misoprostol) 200 microgram
Tablet is inserted into the posterior vaginal fornix every 4 hours for a
maximum of 5 such.
 Intramuscular administration of 15 methyl PGF 2alfa (Carboprost
tromethamine) 250 microgram at three hourly intervals for a maximum of 10
such LCD

SEPTIC ABORTION
12. To discuss 8min What you mean
about the DEFINITION:-Any abortion associated with clinical evidence of infection of the by septic
septic uterus & its contents, is called septic abortion. abortion?
abortion MODE OF INFECTION:-These organisms are normally present in the vagina
(endogeneous)
1. Anaerobic: - Anaerobic streptococci, tetanus bacillus.
2. Aerobic: - Escherichia coli (E. coli), Klebsiella, Staphylococcus,
Pseudomonas.
This infection is spread to the parametrium, tubes, ovaries, or pelvic What are the
peritoneum. clinical features
CLINICAL FEATURES:- of septic
1. Pyrexia abortion?
2. Pain in abdomen
3. A rising pulse rate of 100-120/minute
4. Internal examination reveals offensive purulent vaginal discharge
5. Variable systemic & abdominal findings depending upon the spread of
infection, shown by clinical grading :-
a. Grade-I: The infection is localized in the uterus
b. Grade-II: The infection spread beyond the uterus to the peritoneum ,
tubes & ovaries or pelvic peritoneum Lecture cum
 c. Grade-III: Generalized peritonitis discussion
Grade-I is the commonest & is usually associated with spontaneous abortion. method
Grade-III is almost always associated with illegal induced abortion.

INVESTIGATIONS:-
1. Cervical or high vaginal swab is taken prior to internal examination
2. Blood for hemoglobin
3. Urine analysis Chart What is the
4. Ulrasonography management of
MANAGEMENT:- the septic
1. GENERAL MANAGEMENT:- abortion?
a. Hospitalisation is essential for all cases of septic abortion
b. To take high vaginal or cervical swabs
c. Overall assessment of the cases is done
d. Principles of management are:
 To control sepsis
 To remove the source of infection
 To give supportive therapy to bring back the normal homeostatic & cellular
metabolism. Flash-card
 To assess the response of treatment

GRADE-I:
1. Drugs like antibiotics, Prophylactic anti gas-gangrene serum of 8000 units &
3000 units of antitetanus serum intramuscularly.
2. Analgesics & sedatives Flash-card
3. Blood transfusion
4. Evacuation of the uterus
GRADE-II:
1. Antibiotics
a. Aqueous penicillin G5 million units I.V every 6 hours
b. Ampicillin 0.5-1gm I.V every 6 hours
c. Gentamicin 1.5 mg/kg I.V every 8 hours
d. Ceftriaxone I.G, I.V every 12 hours Lecture cum
e. Metronidazole 500mg I.V every 8 hours discussion
f. Clindamycin 600 mg I.V. every 6 hours method
2. Clinical monitoring :-To note pulse, respiration, temperature, , urinary output
 & progress of the pain , tenderness & mass in the lower abdomen.
3. Surgery:- Flash-card
a. Evacuation of the uterus within 48 hours
b. Posterior colpotomy
GRADE-III:

1. Antibiotics
2. Clinical monitoring
3. Supportive therapy is directed by gastric suction & intravenous saline
infusion.
4. Active surgery:
a. Indications are:
 Injury to the uterus
 Suspected injury to bowel
 Presence of foreign body in the abdomen as evidenced by the
sonography or X-ray or felt through the fornix on bimanual
examination.
 Peritonitis because of collection of puss
 Septic shock or oliguria
 Uterus too big to be safely evacuated per vaginum
b. Laprotomy should be done by experienced surgeon with a skilled
anaesthetist . Even when nothing is found on laprotomy , simple LCD
drainage of the pus is effective.

13. To discuss 2min RECURRENT MISCARRIAGE Define recurrent

about the abortion?
recurrent DEFINITION:-Is defined as a sequence of three or more consecutive spontaneous
miscarriage abortion before 20 weeks.
ETIOLOGY:- A. FIRST TRIMESTER ABORTION:-
a. Genetic factors e.g. balanced translocation.
b. Endocrine & Metabolic:-
1. Poorly controlled diabetic
2. Thyroid autoantibodies
3. Luteal phase defect (LPD) Lecture cum
4. Hypersecretion of Luteinising hormone as seen in PCOS cases is discussion
associated with sub fertility & higher miscarriage. method
 c. Infection: -Transplacental fetal infection
d. Inherited thrombophilia due to protein C resistence which is a natural
inhibitor of coagulation
e. Immunological causes: Autoimmunity & Alloimmunity
B. SECOND TRIMESTER ABORTION:-
a. Anatomic abnormalities which may be congetital or acquired e.g White board
unicorunate uterus, uterine fibroids etc. are responsible for recurrent abortions.
What do you
14. To discuss 2min CERVICAL INCOMPETENCE mean by
about Women suffering from this condition usually abort in the second trimester or go into cervical
cervical the preterm labor. This condition is characterized by the sudden rupture of bag of incompetence?
incompetence water followed by almost painless expulsion of the immature fetus & placenta. This
sequence tends to repeat itself in subsequent pregnancies.
ETIOLOGY: - Lack of sphincter action of the internal os. This may be congenital or
acquired as a result of surgical operation-forcible dilatation of cervix, conisation,
cauterization or amputation.
DIAGNOSIS: - The diagnostic methods described in the nonpregnant state are based
on the documentation of a more dilated internal os than normal. These include
hysterography, easy passage of a no.8 or 10 Hegar’s dilator or easy pulling of an
inflated balloon catheter. During pregnancy demonstration of a short cervix or
funneling of the internal os by transvaginal ultrasound detect an incompetent cervix. In
doubtful cases weekly ultrasound are done between 14 & 24 weeks. However, the
diagnosis remains difficult in most women & is often based on history alone.
MANAGEMENT:-The treatment of this disease is surgical & consists of reinforcing
the week cervix with a suture. The suture is placed after 14 weeks of gestation so that
the early abortion due to other causes is over but not later than 24 weeks. Ultrasound is
done to confirm the fetal viability & to exclude congenital malformations. Any What are the
obvious cervical infection should be treated. types of
CERCLAGE PROCEDURE:-The two types of procedures are to be done:- Lecture cum cerclage
1. McDonald’s suture: - In this suture is simple. A No. 2 monofilament suture is discussion operation?
placed in the body of the cervix near the level of internal os. The suture is method
placed as a purse string so as to encircle the internal os. The suture is tightened
around the cervical os.
2. Shirodkar’s suture: - This is applied in cases of previous failure of
McDonald’s suture or in cases of structural cervical abnormalities. Shirodkar’s
stitch is more complicated & is not frequently used.
 Which act
15. To discuss 1min Legal abortion:- makes abortion
about the legal?
legal abortion Amendments in 1991 to the Abortion Act 1967 allowed for the reduction of
multiple pregnancies where one or more of the fetuses, but not all, may be
terminated.

Deliberate termination of pregnancy before the viability of the fetus is

called induction of the abortion. The induced abortion may be legal or illegal
(criminal).In India, the abortion was legalized by “Medical termination of
pregnancy Act” of 1971, & has been enforced in the year April 1972. The
provisions of the act have been revised in 1975. LCD

16. To discuss 8min Medical Termination of Pregnancy:- Under this act following provisions are
about the laid down:
medical
termination 1. The continuation of pregnancy would involve serious risk of life or
of pregnancy grave injury to the physical & mental health of the pregnant women.
2. There is a substantial risk of the child being born with serious physical
& mental abnormalities so as to be handicapped in life.
3. When the pregnancy is caused by rape, both in cases of major & minor
girl & in mentally imbalanced women.
4. Pregnancy caused as a result of failure of a contraceptive.

Indication of Medical Termination of Pregnancy:-

1. To save the life of the mother

2. Social indication e.g. pregnancy caused by failure of contraceptives or
rape.
Lecture cum Which
3. When child is having any physical or mental abnormality. discussion recommendation
method are there for
Recommendation for Medical Termination of Pregnancy:- MTP?
1. In the revised rules, a registered medical practitioner is qualified to
perform an MTP provided: a) one has got 6 month house surgeon
 training in obstetrics & gynecology. b) One has assisted in at least 25
MTP in an authorized centre & having a certificate. c) One has got
diploma or degree in obstetrics & gynecology.
2. Termination can only be performed in hospitals, established or
maintained by the government or places approved by the government
3. Pregnancy can only be terminated on the written consent of the women.
Husband’s consent is not required.
4. Pregnancy in a minor girl (below the age of 18 years) cannot be LCD
terminated without written consent of parents or legal guardians.
5. Termination is permitted up to 20 weeks of pregnancy. When the
pregnancy exceeds 12 weeks, opinion of two medical practitioners is
required.
6. The abortion has to be performed confidentially & to be reported to the
director of health Services of the state in the prescribed form.

While women of every social class seek terminations, the typical woman who
ends her pregnancy is young, white, unmarried, poor, or over the age of
40.Abortion (known also as elective termination of pregnancy). There are about
1.2 million abortions are performed each year in the United States. Worldwide,
some 20-30 million legal abortions are performed each year, with another 10-
20 million abortions performed illegally. Illegal abortions are unsafe and
account for 13% of all deaths of women because of serious complications.
Death from abortion is almost unknown in the United States or in other
countries where abortion is legally available. In 1969, abortion rights
supporters held a conference to formalize their goals and formed the National
Association for the Repeal of Abortion Laws (NARAL). Lecture cum
discussion
method
In 1973, the Roe v Wade law, in the opinion written by US Supreme Court
justice Harry Blackmun, the court ruled that a woman had a right to an
abortion during the first 2 trimesters (6 months) of pregnancy. He cited the Why parental
safety of the procedures and the basic right of women to make their own consent in
necessary?
decisions.  

Parental consent
 Various federal and state decisions have tried to require parental
notification, waiting periods, informed consent, and abortion
counseling. People against abortion argue that parents need to be
informed about and approve an abortion for a daughter younger than 18
years. Those supporting the rights of a woman to choose abortion say
parental consent is not required for a woman to carry a pregnancy to
term (the birth of a baby), nor do parents need to give permission for a
woman seeking birth control such as pills or an intrauterine device
(IUD). Parents are also not consulted when a woman seeks treatment
for a sexually transmitted disease.

Intact dilation and extraction

 The recently crafted political term partial-birth abortion loosely means

"partially vaginally delivering a living fetus before killing the fetus and
completing the delivery." This definition broadly includes all methods
of second-trimester abortion (done after the first three months of
pregnancy. A 2007 Partial Birth Abortion ban was passed by the
Supreme Court, and although its wording is open to interpretation, it Lecture cum
essentially states that the act of termination of fetal life cannot occur in discussion
a partially extracted fetus. method

Providers

 Various factors over the years have influenced the number of medical
professionals available and trained to perform abortions:The US Food
and Drug Administration (FDA) has approved Mifeprex (mifepristone,
RU-486), a drug for medical abortions. The lack of abortion providers
to perform surgical terminations has led to the popular belief that
individuals not willing or not skilled enough (through training or
 licensure) to perform surgical terminations will be willing to prescribe
medications for medical termination.

 Safety: Legal abortion is a safe procedure. Infection rates are less than
one percent and fewer than 1 in 100,000 deaths occurs from first-
trimester abortions. Abortion is safer for the mother than carrying a
pregnancy to term. Medical and surgical abortions are both safe and
effective when performed by trained practitioners.

 Race: Most women seeking abortion are white (53%); 36% are black,
8% are of another race, and 3% are of unknown race. LCD

 Age: Abortion rates are highest among 20- to 24-year-old women.

17. To describe 5min Rates are lowest among women younger than 20 or older than 40 years
the types of but these women are far more likely to have an abortion if they become Surgically
Abortion pregnant. which methods
according to we use for
the treatment abortion?
Types of Abortion

Surgical

From nine weeks until 14 weeks, an abortion is performed by a dilatation and

suction curettage procedure. Lecture cum
discussion
method
After 14 weeks, surgical abortions are performed by a dilatation and
evacuation procedure.

After 20 weeks of gestation, abortions can be performed by labor induction, Medically which
prostaglandin labor induction, saline infusion, hysterotomy, or dilatation and drugs we use for
extraction. the abortion?

Most abortions are performed in an outpatient office setting (doctor's office,

ambulatory clinic) under local anesthesia with or without sedation.
 Medical

Medical abortions can provide some measure of safety in that they eliminate
the risk of injury to a woman's cervix or uterus from surgical instruments.
Some women require an emergency surgical abortion, and, for safety concerns,
women undergoing medical abortions need access to providers willing to
perform a surgical abortion should it be necessary.

In September 2000, the FDA approved the drug mifepristone (known as RU-
486) for use in a specific medical plan that includes giving another drug,
misoprostol, for those who do not abort with mifepristone alone. Methotrexate
and misoprostol are drugs approved for other conditions that can also be used
for medical termination of pregnancy. Additional research will determine
exactly which drug or combination is ideal for medical abortions.

The process of a medical abortion involves bleeding, often like a heavy

menstrual period, which must be differentiated from hemorrhage (a serious LCD
18. To discuss 2min problem). Regardless of the amount of tissue passed, the woman must see a How we do the
about the doctor for evaluation to make sure the process is complete (and not an abortion
abortion counseling?
incomplete
counseling Lecture cum
discussion
Abortion Counseling method

Most abortion counseling focuses on the decision-making process, the options

for continuing the pregnancy, medical issues of the pregnancy, information
regarding the pregnancy itself, full disclosure of the risks of continuing the
pregnancy to deliver a baby, information and options for the abortion
procedure, and, finally, information regarding a birth control decision. The
risks and benefits of both medical and surgical abortions are often reviewed.

During the counseling, you may be asked questions designed to encourage

meaningful discussion of the issues as they pertain to you. You will have
 many emotions. Counseling may take a day or longer. How we prepare
the patient for
19. To discuss 2min Some state laws may apply to the counseling process. Some states have abortion?
about the
mandatory waiting times between the information session and the actual
preparation
of patient foe
abortion. Other states require family or parental notification, and some states
abortion mandate that certain subjects be covered during abortion counseling

Abortion Preparation

History

1. Health care provider takes a brief and targeted medical history.

2. The provider will ask whether you have a history of diabetes, LCD
high blood pressure, heart disease, anemia, bleeding disorders,
or surgery.
3. If there are known problems with the fetus, such as severe
brain abnormalities. The woman may choose to end the
Lecture cum
pregnancy with abortion. discussion
4. The most common problems with the fetus encountered in method
abortion counseling include major system development failures
and problems that cannot be repaired dealing with the heart,
nervous system, spine, brain, abdomen, kidneys, and breathing
and digestive systems

Physical

A brief physical examination is usually performed before an abortion. The

focus is on determining when your pregnancy began and checking for sexually
transmitted disease and whether you are healthy enough to undergo the
procedure.

Lab tests
 Pregnancy tests are used to confirm that you are pregnant. Home tests are
reliable, so providers will accept these results in some cases. Blood will be
tested for sexually transmitted diseases and for hepatitis. Urine may be checked
to see if you have a urinary tract infection.

Imaging studies

An ultrasound is virtually always dome for pregnancy confirmation and dating.

Doctors are looking for how many fetuses may be developing, the size of the
LCD
fetus or fetuses, a picture of the uterus and ovaries, and to rule out a problem
such as an ectopic pregnancy (a life-threatening condition in which the fetus What things we
develops outside the uterus). have to explain
20. To explain 9min the patient about
the procedure Medications abortion?
of the
abortion Your health care provider may give you antibiotics as a precaution against Lecture cum
infection. Antibiotic use for the procedure is usually given the day of the discussion
procedure and for the next day or two method
Explanation of the Procedures

 1. Women often travel far for their abortion procedure and feel
comfortable completing the preoperative preparation in a short office visit.
In states where laws require waiting periods, this can be done in stages.

 2. The assessment process involves only a targeted history, physical

examination, laboratory work, and ultrasound (including dating of the
pregnancy, if indicated) followed by a counseling session.

 3. Second-trimester abortion preparation is more difficult. Preparing

the cervix in less than 24 hours is almost impossible, but the basic
assessment process is identical.

 4. Ultrasound examinations may be used to look specifically for

 obvious problems with the fetus.

 5. Some centers also offer an intra-amniotic injection of the drug

digoxin, which stop heart activity in the fetus before a second-trimester
abortion.

Medical abortion

 First- and second-trimester medical abortion

o First-trimester (first three months of a pregnancy) terminations

are accomplished medically with misoprostol alone, methotrexate-
misoprostol combination regimens, or Mifeprex (RU-486) with or Lecture cum
without misoprostol. Other prostaglandins are used in other countries. discussion
method
o Medical abortions are indicated for women who consent to a
medical abortion but are also willing to undergo a surgical abortion if the
medical abortion fails. Gestational age is usually less than 42-49 days, but
many protocols can be used, including for gestations up to 63 days from
the last menstrual period.
Which drugs we
o The Mifeprex/misoprostol drugs are given as follows: use in medical
abortion?
 On day one, Mifeprex (200mg or 600mg) as pills are
taken by mouth in the doctor's office.

 On day two or three, misoprostol (800mcg is taken as

pilsl or inserted vaginally) or in an office setting with four hours of
observation.

 Between days 7 and 10, you return to the office to

determine if the abortion has been completed.

 If it has not, a repeat dose of misoprostol is given or

 you may undergo a surgical abortion.

o The methotrexate/misoprostol regimen is similar, as follows:

 Methotrexate is injected on day one.

 On days six to seven, misoprostol is taken at home

vaginally, and you return to the office on day eight to
determine if the abortion has taken place. Misoprostol
can be repeated with monitoring, or surgical abortion
may be completed.

Surgical abortion Lecture cum

discussion
 Cervical dilatation and preparation method

o For a first-trimester termination, particularly at less than 10 LCD

weeks' gestation, rarely do you need to have your cervix dilated (enlarged
so the contents of the uterus can pass through and out of your body). If
you are in the latter part of the first trimester (first three months), you
may have a small sterilized stick called a laminaria japonica (or more
than one) placed in your cervix to open it. These laminaria take about
four hours to be useful and may be placed overnight.
Which methods
o Before inserting the stick, your cervix may be swabbed with we use in
Betadine, a cleaning solution. You may be given an injection of numbing surgical
solution into the cervix. This is the beginning of the abortion procedure. abortion?
Please understand your risks, and they should have been explained in the
counseling process, before you start the dilatation process.

 Sedation during abortion

o Most women are coached through an abortion as the health

care provider explains each step. Some women prefer to have some
 numbing in their cervix. Most do not require IV sedation.

o If heavy sedation is selected, then IV fluids will be used.

 First-trimester surgical abortion

o Early terminations are performed with little cervical dilatation

and using a hand-held syringe or a small-bore cannula (a tube) attached to
a suction machine. Abortions performed with a syringe are referred to as
manual aspirations (or menstrual extractions). Those performed with the
suction generated by a vacuum aspirator are referred to as a vacuum Lecture cum
aspiration. Both procedures take only a few minutes. discussion
method
o Tools are used to grasp the cervix after it has been prepared
with Betadine and possibly numbed. The cannula is carefully inserted
through the cervix into your uterus. The actual evacuation is performed
by applying suction to the syringe or via the machine. The procedure
takes a few minutes to complete. There is a small amount of blood loss.
LCD
o The doctor will check the tissue to make sure it has all been
taken out.

 Dilatation and curettage (D&C)

o This specifically is a term that is usually applied to a

diagnostic procedure or the treatment of an incomplete abortion.

o The procedure is usually accomplished with similar dilatation

procedures, but the uterus is emptied with a sharp metal curette. These
curettes are more dangerous than the flexible or rigid plastic devices,
which are used in the suction procedures, and are not recommended for
abortion procedures.
  Second-trimester dilatation and evacuation

o Dilatation and evacuation is the safest and most common

method of second-trimester termination used by experienced health care
professionals. Dilation takes place over hours and possibly days with the
sticks to enlarge the cervix.

o Once the cervix is enlarged enough, the procedure is

accomplished using a combination of suction curettage and manual
evacuation of the fetus and placenta.  Ultrasound may be used to guide Lecture cum
the tools. discussion
LCD method
o The procedure is longer and more uncomfortable than a first-
trimester procedure, but many women can comfortably go through the
procedure with local anesthesia.

 Dilatation and extraction

o This procedure is accomplished by cervical preparation similar

to cases of dilatation and evacuation, but the fetus is removed in a mostly
intact condition. The fetal head s able to be collapsed after the contents
are evacuated so that it may pass through the cervix. After abortion
21. To discuss 2min what things we
the care after o Very few providers perform the procedure. It is usually have to keep in
the procedure reserved for cases of maternal medical complications or serious medical mind?
problems with the fetus.

o The procedure, referred to as intact dilatation and extraction,

called partial-birth abortion, has now been banned by a 2007 Supreme
Court ruling.

o To avoid performing a partial birth abortion while performing

a legal dilatation and extraction, digitalis or potassium chloride may be
 injected onto the fetus to induce preoperative fetal death. Fetal cord Lecture cum
cutting may accomplish this as well. discussion
method
Research has not firmly established at what age a healthy fetus can feel pain, What is the
22. To describe 1min but generally it is thought that this occurs around 24-28 weeks various
the complication of
complication
After the Procedure transparenc abortion?
of abortion y
1. Activity: You may be referred for ongoing counseling and support
after an abortion. You may eat a regular diet and resume normal
activity. Avoid heavy activity or lifting for a few days. Do not use
tampons, douche, or have sexual intercourse for one week.
2. Medications: You may be given medication for pain, but these are
usually not necessary. Your doctor may prescribe medications for
painful contractions and cramping of your uterus, but with a first-
trimester procedure, none are usually needed. You have pain; your
doctor may suggest acetaminophen (such as Tylenol) or ibuprofen
(such as Advil) and similar pain relievers.

COMPLICATIONS FROM ABORTIONS CAN INCLUDE:

 uncontrolled bleeding
 infection
 blood clots accumulating in the uterus
 a tear in the cervix or uterus
 missed abortion (the pregnancy is not terminated)
 incomplete abortion where some material from the pregnancy remains
in the uterus
What is the
23. To discuss 2min Lecture cum various nursing
the nursing discussion diagnosis of the
process of the method client with
client with Women who experience any of the following symptoms of post-abortion abortion?
abortion complications should call the clinic or doctor who performed the
abortion immediately:

 severe pain
 fever over 100.4°F (38.2°C)
 heavy bleeding that soaks through more than one sanitary pad per hour
 foul-smelling discharge from the vagina
 continuing symptoms of pregnancy

NURSING PROCESS FOR CLIENT WITH ABORTION:-

ASSESSMENT:-
 Vaginal bleeding, spotting, clots
 Low abdominal cramping
 Passing of tissues through the vagina
 Shock, decreased blood pressure, increased pulse rate
 Woman may verbalize fear, disappointment or feeling of guilt
NURSING DIAGNOSIS
 Risk for fetal injury
 Risk for infection
 Ineffective airway clearance
 Actual/risk for aspiration
 Anxiety
 Anticipatory grieving
 Altered family process
  Actual/risk for altered parenting
 Health seeking behavior
PLANNING
 Provide information regarding treatment
 Provide support & reassurance regarding nursing care
 Promote maternal physical wellbeing
 Provide opportunity for counseling & support
 Provide teaching related to self care
IMPLEMENTATION
What is the role
 Observe for vaginal bleeding & cramping
24. To discuss 2min of midwives in
the role of  Save expelled tissues & clots for examination abortion?
the midwives  Monitor vital signs every 5 min to 4 hours depending on maternal status
 Maintain woman on bed rest
 Observe for signs of shock & institute treatment measure
 Prepare for dilatation & curettage if appropriate
Lecture cum
 Provide support, but ovoid offering assurance
discussion
EVALUATION method
Ensure that the woman
 Is free from anemia &/or infection
 Is free from vaginal bleeding
 Returns to normal physiological status following the abortion
 Verbalizes feeling regarding the events & the outcome as does her
significant other/spouse
 Understands self care measures.

Role of Midwives:-

1. Caring for mother whom termination of pregnancy is an option.

25. 1min 2. Antenatal screening or diagnostic tests offered.
To 3. Give accurate & factual information about investigation & possible
summarize
 the topic anomaly to the family.
abortion 4. Adequate support & counseling both before & after the procedure.
5. Social, medical & psychological factors all contributes to the decision
6. Privacy to be maintained.
7. She has to give advice regarding following & future pregnancies
depend on the type of abortion.
8. She should provide the calm & relaxed atmosphere & psychological
support are important to the client during the procedure.
9. Give knowledge to the women regarding complication, after abortion.
10. Vaginal bleeding will continue for 1-3 weeks
11. She should seek for medical device if she develops fever, pain, burning
on micturition.
12. If lactation begin after abortion it is usually mild & last less than 48 hrs
13. Tub bath or immersion baths are should be avoided for at least 1 week.
14. Follow up visits must be made in 24 weeks after abortion.

SUMMARY:-Today I have taught about :

1. Abortion: - Abortion is the expulsion or extraction from its mother of an

embryo or fetus weighing 500 gm or less when it is not capable of
independent survival (WHO).
2. Classification:- spontaneous & induced
3. Threatened abortion: - It is a clinical entity where the process of abortion
has started but has not progressed to a state from which recovery is
impossible.
4. Inevitable abortion: - it is the clinical type of abortion where the changes
have progressed to a state from where continuation of pregnancy is
impossible
5. Complete abortion: - when the products of conception are expelled en
masse, it is called complete abortion.
6. Incomplete abortion: - when the entire product of conception is not
expelled, instead a part of it is left inside the uterine cavity, it is called
26. 1min
To incomplete abortion.
7. Missed abortion: - When the fetus is dead & retained inside the uterus for
 recapitalize a variable period, it is called missed abortion or silent miscarriage or early
the topic fetal demise.
abortion 8. Septic abortion:- Any abortion associated with clinical evidence of
infection of the uterus & its contents, is called septic abortion.
27. 1min 9. Recurrent abortion;- Is defined as a sequence of three or more consecutive
To write the
black board spontaneous abortion before 20 weeks.
summary 10. Cervical incompetence
11. Legal Acts of abortion
12. Medical termination of pregnancy
13. Abortion counseling
14. Preparation of the patient for abortion
15. Role of midwives

RECAPTULIZATION:-
Q1. Define abortion?
Q2. What are the types of abortion?
Q3. In which year the MTP act was passed?

BLACK BOARD SUMMARY:-

1. Spontaneous abortion
2. Classification of abortion
3. Mechanism of abortion
4. Threatened abortion
5. Inevitable abortion
6. Incomplete abortion
7. Missed abortion (silent miscarriage)
8. Septic abortion
28. 9. Recurrent miscarriage
To list the 10. Cervical incompetence
references 11. Legal abortion
for topic 12. Medical Termination of Pregnancy
abortion 13. Abortion Preparation
14. Explanation of the Procedures
15. After the Procedure
16. Role of Midwives

BIBLIOGRAPHY:-
1. D. C. Dutta, “Textbook of obstetrics”, (2004), 6th edition, Published by
New central book agency. Pp:-159-178

2. Mudaliar & Menon, “Clinical Obstetric”, (2005), 10th edition,

published by Orient Longman. Pp:-132-136

3. V. Ruth Bennett, “Myles Textbook for Midwives”, (2001), 13th edn.

Published by Churchill Livingstone.
Pp:-238-243
4. Mrs. Molly Babu, “Case book for Midwives”, (2006), 2nd edn.
Published by Kumar publisher house. Pp:-50
5. Saunders, “Comprehensive Review for the NCLEX-RN Examination”,
(2008), 4th edition. Pp:-278
6. Annamma Jacob, “A Comprehensive textbook of Midwifery”, (2008),
 2nd edition, Published by Jaypee. Pp:-281
JOURNALS:-
1. British journal of obstetrics & gynecology 97: 904-908
2. Iles S 1989 the loss of early pregnancy. Clinical obstetrics &
gynecology 73(4): 769-791
3. Paintain D 1994 induced abortion. In: Clements RV (ed) ch 28, p 355
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