Queensland Health Clinical Excellence Queensland Maternity and Neonatal Clinical Guideline Termination of pregnancy Queensland Clinical Guideline: Termination of pregnancy Document title: Termination of pregnancy Publication date: October 2019 Document number: MN19.21-V5-R24 The document supplement is integral to and should be read in conjunction Document supplement: with this guideline. Amendments: Full version history is supplied in the document supplement. Amendment date: August 2020 Replaces document: MN19.21-V4-R24 Author: Queensland Clinical Guidelines Health professionals in Queensland public and private maternity and Audience: neonatal services Review date: October 2024 Queensland Clinical Guidelines Steering Committee Endorsed by: Statewide Maternity and Neonatal Clinical Network (Queensland) Email: [email protected] Contact: URL: www.health.qld.gov.au/qcg Cultural acknowledgement We acknowledge the Traditional Custodians of the land on which we work and pay our respect to the Aboriginal and Torres Strait Islander Elders past, present and emerging. Disclaimer This guideline is intended as a guide and provided for information purposes only. The information has been prepared using a multidisciplinary approach with reference to the best information and evidence available at the time of preparation. No assurance is given that the information is entirely complete, current, or accurate in every respect. The guideline is not a substitute for clinical judgement, knowledge and expertise, or medical advice. Variation from the guideline, taking into account individual circumstances, may be appropriate. This guideline does not address all elements of standard practice and accepts that individual clinicians are responsible for: • Providing care within the context of locally available resources, expertise, and scope of practice • Supporting consumer rights and informed decision making, including the right to decline intervention or ongoing management • Advising consumers of their choices in an environment that is culturally appropriate and which enables comfortable and confidential discussion. This includes the use of interpreter services where necessary • Ensuring informed consent is obtained prior to delivering care • Meeting all legislative requirements and professional standards • Applying standard precautions, and additional precautions as necessary, when delivering care • Documenting all care in accordance with mandatory and local requirements Queensland Health disclaims, to the maximum extent permitted by law, all responsibility and all liability (including without limitation, liability in negligence) for all expenses, losses, damages and costs incurred for any reason associated with the use of this guideline, including the materials within or referred to throughout this document being in any way inaccurate, out of context, incomplete or unavailable. Recommended citation: Queensland Clinical Guidelines. Termination of pregnancy. Guideline No. MN19.21-V5- R24. Queensland Health.2020 Available from: http://www.health.qld.gov.au/qcg © State of Queensland (Queensland Health) 2020 This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives V4.0 International licence. In essence, you are free to copy and communicate the work in its current form for non-commercial purposes, as long as you attribute Queensland Clinical Guidelines, Queensland Health and abide by the licence terms. You may not alter or adapt the work in any way. To view a copy of this licence, visit https://creativecommons.org/licenses/by-nc-nd/4.0/deed.en For further information, contact Queensland Clinical Guidelines, RBWH Post Office, Herston Qld 4029, email [email protected]. For permissions beyond the scope of this licence, contact: Intellectual Property Officer, Queensland Health, GPO Box 48, Brisbane Qld 4001, email [email protected], phone (07) 3234 1479. Refer to online version, destroy printed copies after use Page 2 of 36 Queensland Clinical Guideline: Termination of pregnancy Flow Chart: Summary of termination of pregnancy Legal requirements ToP Act 2018 Woman requests termination of Less than or equal to 22+0 weeks • pregnancy A medical practitioner may perform a termination upon request At or after 22+1 weeks • A medical practitioner may perform a termination if, in consultation with another medical practitioner, all the below circumstances are met Medical • Circumstances both medical Clinical assessment practitioner(s) practitioners must consider: • Confirm pregnancy assessment as per o All relevant medical circumstances • Medical, obstetric, sexual history ToP Act 2018 o The woman’s current and future • Psychosocial history physical, psychological and social o Screening for domestic violence or circumstances reproductive coercion o Professional standards and o Refer as appropriate guidelines relevant to the practitioners in relation to Examination/Investigations termination • Determine gestational age • Confirm intrauterine pregnancy (exclude ectopic) No • Routine antenatal bloods Proceed to • Refer to antenatal services Ultrasound scan (USS) termination? • Offer opportunistic health care Information • Provide accurate, non-judgemental, Yes easy to understand information on: o Options for the pregnancy Surgical or medical procedure (including palliation/adoption) • Consider: o Methods of termination o Gestation of pregnancy Pre-termination o Contraception o Clinical indications assessment o Post-termination care o Preferences of the woman o Service level capability and Co-ordinate referrals expertise • As clinically indicated o Antibiotics for surgical procedures, • Offer confidential non-judgemental if required counselling • Offer formal mental health referral Consent • Refer to other services (e.g. private • Consider issues of capacity service providers) Surgical or • Consider adequacy of information • Discuss fetal autopsy medical provision and counselling procedure • If less than 18 years: o Assess Gillick Competence o Assess mandatory reporting requirements Post-termination care • Histopathology Co-ordinate referrals • Rh D immunoglobulin • Consider referrals specialist care, • Analgesia requirements termination procedure, psychological • Provide after care advice Post-termination support/counselling • Discuss contraceptive options care • Provide advice on accessing Discuss psychological care • Follow up • Recommend follow-up • Contraception options • Refer as required Conscientious objection • Disclose objection if termination is requested • Without delay, transfer care to other service or to provider who does not have conscientious objection ToP: termination of pregnancy, Rh D: rhesus D Queensland Clinical Guidelines: Summary of termination of pregnancy Flowchart: F19.21-1-V4-R24 Refer to online version, destroy printed copies after use Page 3 of 36 Queensland Clinical Guideline: Termination of pregnancy Flowchart: Medical termination with MS-2 Step Woman requests termination healthcare • Offer non-directive pregnancy • Consider ectopic or PUL related counselling Confirmed No • Refer to QCG EPL and its flowchart • Urinary pregnancy test IUP? Assessment of location and • Ultrasound scan (USS) viability • Counsel about termination options Yes Clinical assessment Pregnancy No Refer to other termination services • Review history (medical, sexual, ≤ 63 days? (medical or surgical) obstetric) • Psychosocial history o Refer as appropriate Yes • Exclude contraindications • Obtain consent • Remove IUD Woman No • Discuss contraception chooses Refer to surgical termination services • Routine antenatal bloods MToP? o If Rh D -ve, Rh D immunoglobulin required • Offer opportunistic health care Yes o Cervical screening test o STI screening Clinician o Smoking cessation advice is registered No MS-2 Step Refer to registered MS-2 Step provider MS-2 step provider? • Provide instructions for self administration Yes • Advise on: o Pain management o Expected bleeding Possible complications Perform o clinical assessment o Accessing emergency care Seeking support if no onset of for MToP o Follow-up bleeding within 24 hours after • Face to face or remote consult Misoprostol • Confirm wellbeing Fertility, contraception and o β-hCG (expect 80% drop) resuming sexual activity o Bleeding ceased Need for follow-up including o o Follow-up in USS if indicated non-judgemental psychosocial o 2–3 weeks • Offer contraception (e.g. short or support/counselling or specialist long acting options) care o Can commence immediately Further follow-up (as indicated) • Bleeding ongoing consider: Yes Well at No USS MToP complete o follow-up? • Consider referral for: o Surgical intervention or o Further misoprostol dose Conscientious objection • Disclose objection if termination is requested • Without delay, transfer care to other service or to provider who does not have conscientious objection β-hCG: beta human chorionic gonadotrophin, EPL: early pregnancy loss, IUD: intrauterine device, IUP: intrauterine pregnancy, MToP: medical termination of pregnancy, PUL: pregnancy of unknown location QCG: Queensland Clinical Guidelines, Rh D: Rhesus D immunoglobulin, USS: ultrasound scan, ≤: less than or equal to Queensland Clinical Guidelines: Medical termination with MS-2 Step Flowchart: F19.21-2-V2-R24 Refer to online version, destroy printed copies after use Page 4 of 36 Queensland Clinical Guideline: Termination of pregnancy Table of Contents Abbreviations ........................................................................................................................................