Learning Objectives
By the end of this section, you will be able to:
- Discuss medically induced abortion
- Discuss surgically induced abortion
- Discuss the role of the nurse when providing education and referral for an induced abortion
A person deciding to end a pregnancy may do so for many reasons. The person may be choosing to end this pregnancy because it was unplanned or unwanted, was the result of a sexual assault, or is likely to impact their health negatively. In some cases, the fetus has a condition incompatible with life. Other reasons can be financial, relationship problems, and other family responsibilities (Hatcher, 2018). Regardless of the reason, each person should be respected and supported throughout the process. The nurse will assess the person’s need for emotional and mental health support, counseling, and social support resources. Many hospitals and clinics have resources available such as postpartum depression assistance from social work, follow-up appointments for postpartum contraception, and mental health and support services. Each state in the United States now has specific laws on the legality of abortion, and nurses are responsible for knowing the laws in the state or states they practice in.
The nurse will assess the person by reviewing a health history and obtaining a last menstrual period (LMP). If the LMP is unknown, an ultrasound might be performed. The nurse will also draw blood for lab work to determine the person’s blood type, hemoglobin or hematocrit, and possibly STI status. The health-care provider and nurse will provide education and obtain informed consent. Two types of abortions are available and will be discussed in this module: medically induced abortion and surgically induced abortion.
Medically Induced Abortions
A medically induced abortion is a termination of pregnancy induced by medications. According to the American College of Obstetricians and Gynecologists (2022b), 25 percent of women in the United States will have an abortion by the age of 45 years. In 2000, the FDA approved a combination of mifepristone (Mifeprex) and misoprostol (Cytotec) for people seeking medically induced abortions but has since restricted access to mifepristone (Hatcher, 2018). Mifepristone, a selective progesterone receptor modulator, acts as an antiprogestin, which causes uterine lining necrosis, softening of the cervix, and contractility of the uterus (ACOG, 2020). Misoprostol, a prostaglandin E1, softens the cervix and induces uterine contractions (ACOG, 2020). The two-medication regimen of mifepristone followed by misoprostol has a 95 percent to 98 percent effectiveness rate when used by people whose gestation is 63 days or less from their LMP (Osuga et al., 2023). If the medications do not induce abortion or the abortion is not complete, an aspiration abortion should be advised (Hatcher, 2018). Side effects reported during medically induced abortions include intense nausea, vomiting, abdominal pain and cramping especially after the misoprostol is taken, and bleeding through fewer than two pads in an hour, with small clots after the products of conception have passed (Osuga et al., 2023).
Time Frames
If the gestational age is less than 70 days, oral mifepristone will be given as a 200-mg dose in the office; 24 to 48 hours later, 800 mcg of misoprostol will be taken at home (ACOG, 2020). Cramping and bleeding will occur and evacuate the uterus of the products of conception. At 7 to 14 days, the person will return to the office for a follow-up to ensure that the uterus is empty and that bleeding is not excessive, and to discuss contraceptive choices for future planning.
Who to See and Who Is Eligible
A person desiring a medically induced abortion will need to see a medical doctor, certified nurse-midwife, or nurse practitioner. The pregnancy is confirmed and gestational age is estimated. Patients who are eligible for medically induced abortions are those who are no more than 63 days post LMP, or 9 weeks; contraindications are suspected ectopic pregnancy, long-term use of corticosteroids, and severe anemia (Hatcher, 2018).
Surgically Induced Abortions
If the patient is more than 9 weeks past the first day of their LMP, they are no longer eligible for a medically induced abortion and will require a surgically induced abortion. A surgically induced abortion is a procedure in which manual dilation of the cervix occurs, followed by emptying of the uterine cavity. Aspiration abortion, done with the patient under local anesthesia, consists of dilating the cervix with a dilator and evacuating the uterine contents using a vacuum aspirator (Brown & Shvartsman, 2023). This procedure can be done up to 13 weeks’ gestation (ACOG, 2022b). Side effects of an aspiration abortion include retained products of conception, undiagnosed ectopic pregnancy, and uterine perforation; emergent symptoms are fever, severe abdominal pain, and bleeding that soaks a pad in an hour (Brown & Shvartsman, 2023). Second trimester abortions (14 weeks’ gestation and greater) can occur due to delayed pregnancy testing, inability to obtain funding, inability to find a provider or clinic that performs abortion services, or diagnosis of major fetal anomalies detected in the second trimester (ACOG, 2013). Other reasons for second trimester abortions consist of preeclampsia, preterm premature rupture of membranes, and fetal demise (ACOG, 2013). From 14 weeks to 20 weeks’ gestation, a dilation and evacuation (D&E) is conducted. The D&E procedure requires a preprocedure cervical prep of osmotic dilators or misoprostol to soften and dilate the cervix (ACOG, 2013). During the D&E procedure, the provider aspirates the amniotic fluid and removes the fetus through the cervix, using forceps (ACOG, 2013). Dismemberment usually occurs as the fetus is being pulled through the cervix; therefore, a suction curettage should be performed to ensure all products of conception are removed (ACOG, 2013). According to ACOG (2013) after 20 weeks’ gestation, induction of labor is usually preferred, using misoprostol, mifepristone, manual cervical dilators (balloon, osmotic dilators), and/or oxytocin (Pitocin). Complications of surgically induced abortions consist of hemorrhage; incomplete abortion, where tissue remains in the uterus; intrauterine blood clots; cervical, uterine, or abdominal trauma; uterine perforation; and infection (ACOG, 2013; Hatcher, 2018).
Nurse’s Role in Induced Abortion
Trained counselors meet with pregnant persons to provide all the options (abortion, parenting, and adoption) prior to deciding on abortion. The counselors also provide education, support, and referral for counseling for the person and their partner because of emotional and mental health needs after the procedure. Once the person has made an informed decision, they meet with the nurse. The nurse provides education prior to the abortion. For a medical abortion, the nurse explains the action of the medications, how to take them, what to expect, and how to follow up. For surgical abortion, the nurse explains the sedation to be used, dilation of the cervix, removal of the products of conception, and the need to return for a follow-up appointment. The nurse recommends taking ibuprofen (Motrin) or acetaminophen (Tylenol) for cramping pain. Consent forms are also reviewed.
Postprocedure education is provided by the nurse, including emergency contact information and instructions to call if bleeding has soaked two or more large pads per hour for 2 hours, if the temperature is greater than 100.4° F (38° C), and if abdominal pain with nausea or vomiting is present more than 24 hours after misoprostol (Hatcher, 2018). A discussion of hormonal withdrawal and the effect on the emotions of the patient should take place to prevent any psychologic issues after abortion (Coleman, 2018) The administration of Rho(D) immune globulin (RhoGAM) to the patient, if they have an Rh-negative blood type, is required, along with education regarding the use of RhoGAM. Any time RhoGAM is given, a copy of the administration card with date and dose given is provided to the patient for their medical record keeping at home. The nurse also reviews that the patient should refrain from vaginal coitus, inserting a tampon, or using a douche for 2 weeks. Last, the nurse instructs when the patient should return for contraception counseling.
Nurses working in abortion care can experience many emotions. According to research by Qian et al. (2021), many nurses and providers of abortion care experience burnout and emotional trauma. This research noted that providing abortion care caused many negative and positive emotions for nurses, and many nurses felt they lacked support from family, friends, and nurse colleagues due to the mixed emotions surrounding abortion. This research noted that nurses created coping strategies to support their patients but had to learn to conceal their own emotions. This study suggested the development of employee assistance programs to include psychologic care, cognitive behavior therapy, and professional support for nurses working to provide abortion care.
Some nurses feel a moral responsibility to refuse to provide abortion care. According to the American Nurses Association’s Code of Ethics (2015), in times of moral distress, nurses must express their moral concerns to the appropriate authority. This conscientious objection to being a part of the situation must be communicated in a timely and appropriate manner. Nurses are to maintain patient safety, avoid abandonment of the patient, and leave the patient only when nursing care is continued by others. Nurses must use self-evaluation to determine their moral limits and must follow this code to protect themselves and their patients.
Legal and Ethical Issues
Contraception as a Basic Human Right
Recently, two judges in the United States issued contradictory decisions that have the potential to impact access to medically induced abortions for people who are requesting them. In Texas, Judge Matthew Kacsmaryk ruled that the Food and Drug Administration improperly approved the use of mifepristone (Mifeprex) more than 20 years ago. This ruling made it illegal for clinicians to prescribe the drug for patients requesting early term abortions (prior to 10 weeks pregnant) (Savage & Belluck, 2023). Within hours of that decision, U.S. District Judge Thomas O. Rice issued a ruling in Washington State seeking to block the FDA from removing the drug from the market. Abortions became illegal in 14 states in 2022 after the Supreme Court ruling on Dobbs v. Jackson Women’s Health Organization, nearly 50 years after Roe v. Wade. Other states in the United States allow abortion but have limits of 12 weeks’ gestation or less.
The United Nations Population Fund (UNPFA) believes that the consequences of these decisions are serious, and that contraception is in fact a basic human right. According to the 2023 UNPFA Annual Report, the world population recently reached 8 billion lives. They write, “It is the basic right of every individual to decide freely the number, spacing and timing of their children” (Garbett, 2023). The report states that it is the job of our society to advocate to guarantee the ability of persons to make reproductive and sexual decisions free of discrimination, coercion and violence and to provide access to contraception methods that are affordable, accessible, and meet international standards of quality (Garbett, 2023).