Remote Primary Health Care Manuals

Unplanned pregnancy

   

  • Half of all pregnancies in Australia are unplanned
  • Many women need time, information and support to make a decision about their pregnancy
  • Important to respect whatever decision is made. In Australia, women have the right to choose whether to continue or end a pregnancy
  • If woman is legally able to give consent — the decision about pregnancy is hers alone
    • She can tell you who else should know (eg family, partner, health carer)
    • She can't be coerced (forced) to make a particular decision
  • Don't judge the woman
    • Be private, confidential, objective and supportive
    • Aim to support any decision of the woman and provide relevant information and care
  • There may be sensitivities about this pregnancy — concerns about
    • Woman being too young
    • Ability to care for baby
    • Domestic/family violence, pregnancy from sexual assault
    • Pregnancy from wrong skin relationship
  • Beliefs and attitudes about pregnancy and termination of pregnancy vary among women. Respect these beliefs
Red Flags — Urgent Medical Consult
  • All women wanting termination of pregnancy

Do

  • Refer immediately to appropriate agency and follow your organisation’s procedures if
    • Woman would not have been able to consent to sex
    • Woman is a survivor of domestic/family violence or sexual assault
    • Mandatory reporting is a legal requirement
  • Refer to someone suitable in your clinic or to appropriate service if
    • You don't have enough knowledge
    • You have strong beliefs that are different to the woman's and you can't be objective
    • Woman doesn't want to be assessed in her community
  • Talk about main options — don't always need to work out pregnancy dates before talking about choices 
    • Continuing pregnancy and becoming a parent
    • Termination of pregnancy (abortion)
    • Adoption or fostering
  • Actively work with woman to help her make the best decision — this process can involve listening, talking, sharing information or regular meetings
    • Woman may need some time to come to her decision
    • Encourage her to return to discuss her choices further. Help her decide who to share the decision with
    • Offer formal face-to-face or telephone counselling, if available
  • Offer first antenatal visit pathology tests
  • Aim for referral within 1 week of making a decision — regardless of choice or pregnancy dates

Pregnancy choices 

Continuing pregnancy

Termination of pregnancy (TOP)

  • Risks to woman and her future fertility from TOP are less than from pregnancy or birth
  • Regional TOP services vary — affected by resources, TOP providers and legislation
  • If health professional has conscientious objection to TOP — must immediately refer to another doctor who doesn't object
  • Once woman has decided to have TOP
    • Urgent medical consult straight away — there are legal time frames for when a TOP can be done. These vary by state/territory
    • Ask doctor what is needed for referral, travel, TOP preparation — differs between providers and states/territories

Do

  • Talk with woman about
    • Decision to have TOP — explain the risks and benefits of Surgical Termination of Pregnancy (STOP) and Early Medical Termination of Pregnancy (EMTOP)
    • TOP procedure
    • Referral
    • Follow-up

TOP procedure

  • TOP done surgically (operation with anaesthetic) or medically (tablets) — method depends on local services, TOP providers, number of weeks pregnant
    • Medical TOP can be done up to 9 weeks pregnant
    • Surgical TOP best done before 12 weeks pregnant
  • Give information on procedure from local provider or use Children by choice website — most TOP providers have consumer information available about TOP
  • Usually need to travel to regional or major centre. Although some doctors are licensed to prescribe for medical TOP
    • Help woman organise accommodation and childcare if needed
  • Check if woman
    • Wants someone for support — in consult, for travel, after procedure
    • Is able to provide consent

Referral

  • TOP provider will need a referral which could include
    • Reason TOP recommended — choice, health including social and emotional
    • Health summary, medicines, Medicare number
    • STI check — self-collected vaginal swabs or urine
    • Blood group and antibody screen
    • Pregnancy dates
    • Contraception plan
  • Confirm appointment date with TOP provider
  • In some states/territories woman can self-refer to provider — need to understand your legislation and policy

Pregnancy dates

  • Confirm pregnancy — see Pregnancy testing
  • Use pregnancy wheel to work out pregnancy dates — see Antenatal care 
  • Single blood test for hCG level is not reliable for pregnancy dating
  • Palpable uterus is not a good guide for more or less than 12 weeks pregnant
    • Do ultrasound, if available in clinic and skilled — do not delay referral if ultrasound not available
    • If unsure of any findings — specialist/medical/midwife consult

Follow-up

TOP provider should give woman information on what to expect after TOP

  • Woman can be fertile 2 weeks after TOP — contraception plan important
  • Nausea usually settles in days
  • Breast tenderness may last for weeks
  • Normal period expected after 4 weeks, if not using hormonal contraception

Review woman 3 weeks after TOP

  • Do urine pregnancy test — can remain positive for many weeks
    • If weak positive — retest in 2 weeks
    • If strong positive or other concerns that pregnancy is ongoing — medical consult. Very small risk that TOP has failed
  • Ask about any problems
  • Ask how she is feeling. Women may feel sad after TOP or miscarriage but range of emotions normal — check if woman would like a referral for counselling support
  • Ask about current contraception. If nothing — discuss options
  • Check  pathology has been followed up

Contraception plan

  • Discuss contraception options — LARC is best
  • Check what local provider offers — may put in ENG-implant or IUD

Adoption

Adoption is a legal process and varies between state/territories

  • Counselling begins well before the birth of child
  • Get support from relevant adoption services or departments
  • Medical consult

Fostering

Fostering can be a legal or informal process. May be short-term, long-term or permanent

  • Foster carers are often relatives
  • Get advice from relevant foster and kinship care agency or department in your state/territory