Guide for Completing Form 1

Guide for Completing Form 1 - Notification of Induced Abortion a) Submit one completed form for each pregnancy terminated by an induced abortion procedure or procedures. If a fetal reduction procedure is provided and pregnancy is ongoing, one form only should be submitted regardless of number of fetuses terminated. b) Where complications occur and follow-up procedures are required, these should be included in methods, if known, at the time of reporting. However, follow up procedures occurring after abortion procedure has been reported do not require reporting as a secondary, or follow up notification. c) Ensure legibility on all two copies of the form by: Placing form on a firm surface Using ballpoint pen Print all text in BLOCK LETTERS Limit abbreviations to those in common use. d) Ensure completeness by providing responses to ALL questions. e) Ensure timely submission by forwarding the WHITE ORIGINAL form to the Maternal and Child Health Unit at the WA Department of Health within 14 days of abortion. f) Ensure correct reporting by reading description of data below before completing the form. Medical Print full name of medical practitioner performing the abortion. Practitioner Address Print full address of place where abortion was performed. If medication prescription is performed from a General Practice please write name of GP practice and not “woman’s home” or her private address. Date of Abortion The day, month and year (DD/MM/YYYY) when abortion procedure started. If medical abortion, please indicate date of administration of first tablets (i.e. mifepristone). This is not the date abortion was confirmed as completed nor the date of any follow up procedure for that pregnancy. 1. Gestational Age Estimated completed weeks of pregnancy gestation at time of abortion based on first day of Last Menstrual Period or dating ultrasound scan. 2. Method Report one or more method (s) used for the abortion procedure. Methods used later to manage unexpected complications of the procedure may be included if known at time of reporting. Vacuum aspiration (suction curettage) –cannula of appropriate size is inserted, uterine contents are removed by vacuum aspiration (curettage may also be performed) Dilation and curettage (sharp) – cervix is dilated, forceps or curette is inserted to remove uterine contents Dilatation and evacuation – cervix is dilated, uterine contents removed by surgical instrumentation Vaginal prostaglandin or analogue instillation – vaginal misoprostol is administered to soften and dilate the cervix Other (Specify) – method not described above used to induce abortion. Options for reporting: a) “MS 2step” or “Mifepristone” or “Misoprostol” is reported when oral or buccal Mifepristone/Misoprostol is used b) “KCL” or “Cord Ligation” is reported only when this method is used for fetal reduction 3. Reason Report one item only, as the principal reason for abortion: Reason other than fetal abnormality –absence of fetal abnormality: (a) the woman has made an informed choice not to continue her pregnancy, or (b) continuance of the pregnancy would result in serious risk to the life; physical or mental health of the woman Suspected fetal abnormality – prenatal screening/investigations indicate an abnormality or woman is concerned by an increased possibility of fetal abnormality Fetal abnormality – fetal abnormality has been diagnosed Specify if known – the fetal abnormality as determined before the procedure, described in free text. It is recognised that information resulting from postmortem studies will not be available. To prevent rare conditions from enabling identification of individuals, options for reporting complex conditions are: a) “Genetic” or “Chromosomal” would indicate conditions of trisomy, inherited metabolic etc b) “Syndromic” would indicate conditions of no confirmed genetic basis like sirenomelia, short body stalk Selective reduction of multiple pregnancy –termination of one or more fetuses of a twin or higher order pregnancy to preserve the health of the mother or the remaining fetuses. Includes where twin has abnormality. It is planned that the pregnancy will continue with one or more live fetuses. 4. Age The woman’s age in number of completed years at last birthday. 5. Origin of patient Select one item only to indicate the Aboriginal status with which the woman identifies herself. 6. Postcode The postcode of the suburb of the woman’s usual residential address. If outside of Australia, report 8888. Signature Signature of medical practitioner who performed the abortion procedure. Date The day, month and year (DD/MM/YYYY) when this Notification (Form 1) was completed by the practitioner. To reorder or seek more information go to ww2.health.wa.gov.au/Articles/A_E/Abortion-Notification-System health.wa.gov.au © Department of Health 2016 .

Load more