Being faced with a request to refer for termination of pregnancy is common in general practice and knowing how to handle the situation confidently and sensitively is in both your own and your patients' best interests.
Induced abortions, or terminations, are one of the most commonly performed gynaecological procedures, with over 98 per cent being performed due to the risks to the mental or physical health of the woman or her child.
Making the decision
Making the decision to terminate a pregnancy is life changing for those involved. Confidentiality should be assured at all times.
Women should be encouraged to consider the alternative options, including continuing with the pregnancy and adoption. If at all possible, it is worth seeing the woman again the following day to allow her time to digest the information. Bear in mind that those with a poor social network may need extra support.
It is important to be able to calculate the gestation with reasonable certainty in order to refer for the most appropriate form of termination. An abdominal examination is also worthwhile in order to exclude a concealed or late pregnancy.
The Abortion Act 1967
Induced abortions are legal up to 24 weeks of gestation in Britain under The Abortion Act 1967, but illegal in Northern Ireland. In cases of substantial risk to maternal life or severe fetal anomalies, the upper limit of 24 weeks is not applicable.
In order for abortion to be legal, two doctors - one of whom can be the doctor referring the patient - must agree that the pregnancy is subject to one of the five grounds specified on the HSA4 form (blue form) as laid out by the Regulations of The Abortion Act. These five grounds are:
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 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 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 existing children 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.
The majority of terminations are completed on the basis of C or D. The Abortion Act provides a conscientious objection clause for doctors unwilling to sign the blue form for termination, with one of the caveats an obligation to treat women whose lives are in danger.
Confidentiality and consent
The rules on confidentiality and consent apply to terminations in the same way as any other situation.
Minors under the age of 16 years must be deemed Fraser competent prior to consent being given. While they should be encouraged to involve their parents or guardians in their situation, they have the right to confidentiality and this should not be broken unless there is any suspicion of child abuse or exploitation.
Those with parental responsibility are the only ones who can give consent for a termination on behalf of a minor who is not deemed to be Fraser competent.
Abortion procedures are either medical or surgical, depending on the gestation of the pregnancy and where possible, the woman's own preference. See the diagram below for recommended methods of abortion for different gestations.
The choice is essentially between medical and surgical termination. Each has its risks and benefits. Medical terminations require at least two visits to the hospital or clinic and can result in prolonged bleeding, and approximately 2.5 per cent of cases need to be followed by a surgical termination due to failure.
Surgical termination is a quicker procedure and better suited to those who do not want to be aware of the abortion, but it does involve an anaesthetic.
In reality, the majority of women present at around eight weeks of gestation and so at this stage have a choice of either surgical or medical termination.
At over nine weeks of gestation, medical termination requires repeated doses of prostaglandins.
Women need access to both physical and psychological support and follow-up after their termination. Ongoing contraceptive needs should also be addressed.
1. Terminations are legal up to 24 weeks' gestation in England, Scotland and Wales, and later if substantial risk to the mother exists or there is severe fetal anomaly.
2. Two doctors need to sign the HSA4 form (blue form) but there is a clause in The Abortion Act providing for those with conscientious objections.
3. The main forms of termination are medical or surgical and the method used will depend on both the time of gestation and the woman's preference.
4. Ongoing contraception must be discussed and arranged.
Dr Kular is a GP registrar in Nottingham. This topic falls under section 10.1 of the GP curriculum 'Women's Health'.