6. AFTERCARE AND CONTRACEPTION This chapter will help you to provide routine aftercare and contraception following first trimester uterine aspiration. CHAPTER LEARNING OBJECTIVES Following completion of this chapter, you should be better able to: □ Appropriately prescribe post-procedure medications. □ Provide post-procedure counseling, including instructions about home care, warning signs for complications, and emergency contact information. □ Describe post-aspiration contraceptive options and contraindications to specific methods. READINGS / RESOURCES □ National Abortion Federation (NAF). Management of Unintended and Abnormal Pregnancy (Paul M. et al, Wiley-Blackwell, 2009) • Chapter 14: Contraception and surgical abortion aftercare □ Useful handouts for physicians and patients: • Reproductive Health Access Project: www.reproductiveaccess.org • RHEDI: http://rhedi.org/patients.php □ Related Chapter Content: • Chapter 5: Delayed post-procedure complications • Chapter 7: Medication abortion follow-up visit • Chapter 8: Early pregnancy loss follow-up visit SUMMARY POINTS SKILL • Providing women with instructions for home care, medications, contraception, warning signs for complications, and emergency contact information may help minimize patient stress, phone calls, and the need for a routine follow-up appointment following aspiration. • A critical component of abortion care involves contraceptive counseling, method selection, and timing of initiation. SAFETY • Be familiar with the medical eligibility criteria for safely initiating contraceptive methods for women with medical conditions. ROLE • Women with a history of abortion remain at risk for unintended pregnancy; 47% of procedures are repeat procedures. • Starting contraception on the day of uterine aspiration increases initiation and adherence to the method. • Most women are candidates for long acting reversible contraceptives (LARC, including IUDs and implants), which are highly effective, can be placed the day of aspiration, have no estrogen, and users have lower rates of repeat abortion. • Offer to dispense or prescribe emergency contraception to all women following aspiration, since they are more likely to use it with ready access. • You play an important role in empowering a patient to find a contraceptive method that really works for her, ensuring that there are no contraindications, answering questions, and dispelling contraceptive myths. ROUTINE POST-ABORTION CARE Care of women following uterine aspiration is usually straightforward and can occur in an exam room where the procedure was done or a recovery room. Care may vary slightly with the gestational age of the pregnancy, the type of anesthesia, and any complicating factors. Post-aspiration care includes discharge education, surveillance for immediate and delayed complications, as well as observation and support related to analgesia administered. A critical component of post-procedure care is initiation of the contraceptive chosen by the patient. RECOVERY AND MONITORING Provider or staff should assess the following parameters prior to discharge: • adequate pain control. • absence of excessive vaginal bleeding. • normal, stable vital signs. • normal oxygen saturation if IV sedation was used. • ability to ambulate independently. The following discharge medications are given or reviewed for home use: • additional antibiotics (depending on prophylactic regimen). • NSAIDs for prn use. • uterotonics as needed, particularly with advancing gestations > 12 weeks. • preferred contraceptive or prescription, including emergency contraception. Most women require only 20-30 minutes of recovery time, including those receiving local anesthesia, NSAIDs, oral opioids or anxiolytics, or short-acting IV sedation. With any sedating medications, a woman should not drive and should be discharged to the care of a person who will escort her home. Discharge education should include anticipatory guidance deciphering normal symptoms from warning signs for complications and instructions should they occur (see below). Contraceptive methods can be placed, dispensed or prescribed on the procedure day. While some patients may have specific indications for a follow-up visit after uterine aspiration, there are minimal data to support routine use (Grossman 2004). Most women can be given aftercare instructions and a phone number to call with concerns, in lieu of in-person follow-up visit, but specific indications for one include: • suspected incomplete abortion or ongoing pregnancy. • concern for ectopic pregnancy. • additional contraceptive reinforcement. • IUD string check. • psychosocial concerns. Staff should also assess the need for further psychosocial counseling on the day of the procedure. Some clinics offer routine telephone follow-up as an additional option. WHAT TO EXPECT AFTER A UTERINE ASPIRATION Adapted from RHAP & RHEDI MVA AFTER-CARE INSTRUCTIONS Following an abortion or uterine aspiration, your patient will likely feel fine when she goes home. She can usually go back to her regular activities by the next day. She can take a shower as soon as she wants. She can eat normally, and her nausea should go away within a day. Are there things she should not do? Yes. For one week, avoid placing anything vaginally (except for the vaginal ring). To be safe, avoid tampon use, douching, and sex. WHAT TO EXPECT Vaginal Bleeding: She can expect to have bleeding for up to 2 weeks. Some women have bleeding that starts and stops, some women have no bleeding for a few days followed by bleeding like a period, and others have only spotting. Cramping: Some women have cramps off and on during the week. She can use a heating pad or pain medication like Ibuprofen, Naproxen, or Acetaminophen. Sadness or feeling very emotional: Most women feel very relieved when the abortion is over. Some women also feel sad, feel like crying, or are moody after an abortion. Feeling emotional at this time is normal. If she thinks her emotions are not what they should be, recommend she contact the clinic and/or return for follow-up. When will menses resume? She can expect a period in 4-8 weeks. It is not the same for all women or with all contraceptive methods. She should call us if any of the following warning signs occur: -bleeding that soaks through more than 2 maxi pads per hour for more than 2 hours. -cramps that are getting stronger and are not helped by pain medication. -temperature higher than 101 degrees. To reach the clinic: Give her a 24-hour contact number. If she has any questions, thinks something is going wrong, or thinks she is having an emergency, she should call the contact number; assure her a call back within 10-15 minutes. Acknowledge that this may be a tough time for her, so if she forgets something or is worried, she should not hesitate to call. If indicated, give her a follow-up visit. PREGNANCY PREVENTION A woman can get pregnant before her period returns. If she initiates a birth control method the day of aspiration and abstains from intercourse for one week, she does not need a back up method of contraception. She should start using the method today if possible. If she has sex without protection, emphasize that she can use Emergency Contraception (EC) to decrease her chance of another pregnancy. PSYCHOSOCIAL SUPPORT Studies have shown that quality of life measures and mood improve in the month following surgical aspiration. Repeated studies since the 1980’s have concluded that abortion does not pose a hazard to women’s mental health, although some women may experience worsening depression or other psychiatric disorders. Many providers routinely provide information about an available national hotline that addresses the emotional health and wellbeing of women and men following abortion (www.exhaleprovoice.org or 866-4EXHALE). Providers should identify women who may benefit from further counseling or referral. CONTRACEPTIVE CARE Tips for Effective Contraceptive Counseling • Start with broad goals: “When, if ever, do you want to have (more) children?” • Be patient centered: “What are you looking for in a birth control method?” • Introduce methods by tiers of effectiveness (LARC > hormonal > barrier). • Refer to typical use failure rates (not perfect use). • Emphasize positive side effects (less bleeding, acne, or remembering). • Ask “Do you want to have a period each month?” • Screen for medical eligibility (using US Medical Eligibility Criteria). • Acknowledge common challenges (remembering, appointments, supplies). • Dispel common myths (i.e. “IUDs cause infertility”). Comparing Effectiveness of Birth Control Methods chart Source: WHO, 2007 CURRENT EVIDENCE BASED DEVELOPMENTS IN CONTRACEPTION Simplified screening prior to prescribing hormonal contraception (Stewart 2001) • Medical History to screen for contraindications to estrogen or progestin. • Exam components required for specific method initiation: o Combined hormonal methods: Blood Pressure o DMPA: Weight/BMI o IUD or diaphragm: Pelvic exam +/- STI screening (at placement) • Not required: o Pap test, pelvic, lung, heart, and breast exam o Hemoglobin and routine lab tests o STI risk assessment and testing; consider in women ≤ 25 or high risk. Evidence for prescribing or dispensing a full year of hormonal contraception • Office protocols should minimize barriers for appointments, supplies, and refills. • Providing (or prescribing) a year's supply lowers cost, improves continuation, and improves prevention (Foster 2006). Pap screening guidelines (2012 USPSTF, ACS / ASCCP) • Pap every 3 yrs