Consultation skills - Discussing pregnancy termination

The role of the GP is to listen to the patients' wishes and not pass judgment, says Dr Lynda Carter.

Ask the patient why she wants a termination and find out whether she has discussed it with the father (Photograph: Alamy)
Ask the patient why she wants a termination and find out whether she has discussed it with the father (Photograph: Alamy)

The 1967 Abortion Act governs termination of pregnancy in the UK mainland (England, Scotland and Wales) but not Northern Ireland. This was amended in 1990 by the Human Fertilisation and Embryology Authority.

Terminations can be carried out if:

1. Continuing the pregnancy involves risk to the life of the pregnant woman greater than if the pregnancy were terminated.

2. It is necessary to prevent grave permanent injury to the pregnant woman's physical or mental health.

3. The pregnancy has not exceeded its 24th week and there is a risk, greater than if the pregnancy were terminated, of injury to the physical or mental health of the pregnant woman or the existing children of the pregnant woman.

4. If the child were born it is at substantial risk of being seriously physically or mentally handicapped.

Two doctors must certify that the legal grounds are met, unless it is an emergency.

Usually, the first doctor is the GP and the second is a doctor who works at the hospital or clinic where the abortion will take place.

Managing your feelings
There is a conscience clause in the Abortion Act so that no one can be forced to participate in any abortion if he/she has conscientious objection to it.

If this applies to you, when you see a patient requesting a termination, you have a legal and professional duty to make sure the patient sees another GP as soon as possible. Make sure your GP colleagues are aware that you are a conscientious objector as they will need to sign the HSA1 form and refer the patient.

At least one third of British women will have had a termination before the age of 45.

Ninety-eight per cent of terminations are carried out under the clause 'would cause risk to the mother's physical or mental health'.

Involvement in terminations for a social reason may be difficult for some doctors. This may be particularly so if the doctor has had a termination in the past and regretted it or if the doctor, or someone close to them, is having fertility problems.

However the role of the doctor is to listen to the patient's wishes and not pass judgment.

What to do when a patient asks for a termination

  • Perform a pregnancy test if there is any doubt of pregnancy.
  • If you have concerns about dates, arrange an ultrasound for dating.
  • Listen to and counsel the patient. Allow her to ask any questions she has. Ask why she wants a termination and whether she has discussed it with the father, her parents or her friends.
  • Ask whether she has already made her decision or if she would like more time to think about it, with follow-up in a couple of days. Reinforce that she can change her mind at any point until the procedure.
  • Sign the HSA1 form (or refer to a colleague as soon as possible if you are a conscientious objector) and refer the patient. The earlier in pregnancy a termination is planned the lower the risk of complications.
  • Ask the patient if she would like any information at this stage about the different kinds of procedures available.
  • Discuss future contraception to start straight after the termination.
  • Follow-up should be within two weeks of the procedure with either the referring GP or the termination of pregnancy service.

The options
Medical terminations can be used from four to nine weeks using a single oral dose of the antiprogesterone, mifepristone, followed by a single dose (vaginal or oral) of prostaglandin.

From nine weeks to 24 weeks, mifepristone can be used followed by multiple doses (vaginal or oral) of prostaglandin. There are some contraindications to having a medical termination.

Conventional surgical termination occurs from seven to 15 weeks with suction termination, under either general or local anesthetic, where the uterus is emptied using a suction curette. Surgical terminations after 15 weeks use a combination of suction and specialised forceps.

Potential side-effects include pain and bleeding for both types of termination. Nausea, vomiting and dizziness are common side-effects of medical termination. The possible risks are haemorrhage, infection, uterine perforation and damage to the external cervical os in surgical termination and uterine rupture with second trimester medical terminations. With all first trimester abortions there is a possibility of a failed procedure with an ongoing pregnancy.

This risk is greater with medical compared with surgical terminations.

  • Dr Carter is a locum GP in West Yorkshire.

Resource

Reflect on this article and add notes to your CPD Organiser on MIMS Learning

CPD IMPACT: EARN MORE CREDITS

These further action points may allow you to earn more credits by increasing the time spent and the impact achieved.

  • Hold a practice meeting to find out whether any colleagues are conscientious objectors to termination of pregnancy. If so, develop a practice system to ensure patients are referred on quickly.
  • Familiarise yourself with your referral procedure for medical and surgical terminations and find out what other services are available in your area.
  • Collect some good quality patient information leaflets and share them with colleagues in your practice.


 

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