An abortion is a procedure to end a pregnancy. It uses medicine or surgery to remove the embryo or fetus and placenta from the uterus. The procedure is done by a licensed health care professional. The decision to end a pregnancy is very personal

1. ABORTION
MUKESH SAH, MD
PGI
GOODSAM MEDICAL CENTER

2. ABORTION
• Abortion is the expulsion or extraction from its mother of an embryo or
fetus weighing 500g or less when it is not capable of independent
survival (WHO).
• This 500g of fetal development is attained approximately at 22 weeks
(154days) of gestation.
• The expelled embryo or fetus is called abortus.
• The term miscarriage is the recommended terminology for spontaneous
abortion.

3. TYPES OF ABORTION
1. Spontaneous (miscarriage)
a. Isolated (sporadic)
b. Recurrent
- Threatened
- Inevitable
- Complete
- Incomplete
- Missed
- Septic (less common)

4. 2. Induced
a. Legal (MTP)
b. Illegal (unsafe)

5. SAFE ABORTION CARE (1/2)
• “preventing unwanted pregnancies through a quality family planning services
is a first step towards addressing women’s reproductive health needs, and
increasing access to safe abortion services has been considered as a missed
opportunity to prevent unwanted pregnancy.
• When women become pregnant, it is always not end with live birth. In some
cases termination of pregnancy occurs before the due date.
• Abortion is defined as the death or expulsion of the fetus either spontaneous
(also called miscarriage) or by inductive before the 28th week of pregnancy.

6. SAFE ABORTION CARE (2/2)
• It is the expulsion or extraction of all or any part of the placenta or
membranes, without an identifiable fetus or with a fetus (alive or dead)
weighing less than 500g.
• Induced abortions are carried out surgically, or medically, safety or
unsafely.
• The primary cause of abortion is unplanned pregnancy.

7. SAFE ABORTION SERVICES IN NEPAL (1/2)
• The act of abortion was considered a criminal act in Nepal before its
legalization in March 2002.
• The bill received Royal assent in September 2002, with the procedural
order enabling the implementation of the new receiving final approval in
December 2003.
• First safe abortion was carried out in 2004.

8. SAFE ABORTION SERVICES IN NEPAL (2/2)
• Even though the new abortion law legalized the abortion under specified
conditions, the ingrained fear and stigma still prevails in the society and many
women are still terminating pregnancy by unskilled person to maintain privacy
and secrecy.
• First National safe Abortion care is integrates in Safe motherhood program of
Nepal to make it more accessible and acceptable. Safe abortion services is
scaled up in all the districts up to primary health care center level (PHCC).

9. WHY THE RIGHT OF THE SAFE ABORTION
IS REQUIRED
• Every year 22 million unsafe abortions occur in the world, resulting in the
death of an estimated 47000 women and disabilities for an additional 5
million women (source: safe abortion: technical and policy guidance for
health systems, WHO 2012).
• Everyone is entitled to sexual and reproductive rights.
• Clinical indicators like
- genetic abnormality in the fetus.

10. - Cardiovascular disease such as sever hypertensive disorders.
- High risk of uterine injury.
- Trophoblastic disease
- End stage cancers, end stage AIDS
- Rupture of membranes before fetal viability
- Intrauterine infection.

11. SAFE ABORTION SERVICES IN NEPAL
• Global and national evidence shows that many women face unwanted
pregnancy including due to limited access to family planning information
and services.
• Such a women who can not access safe abortion services in a timely way are
at a high risk of developing complications due to unsafe abortion, or in the
worst case, suicide due to social pressure.
• Thus the there is need to make safe abortion services available, accessible
and affordable to all women with unwanted pregnancies.

12. ACTION UNDERTAKEN TO INITIATE SAFE
ABORTION CARE (1/5)
The national Reproductive Health Strategy, 1998 accepted prevention and
management of abortion as one of component of integrated reproductive health
package and thus an important indicator of the nation’s overall health status.
Following efforts were undertaken to initiate abortion services in Nepal:
 The National Medical Standard for Reproductive Health for Reproductive
Health Volume II: other Reproductive Health Issues has set standard for Post
Abortion Care in different level of health facilities in Nepal.

13. ACTION UNDERTAKEN TO INITIATE SAFE
ABORTION CARE (2/5)
 In December 2000, the Ministry of Health organized in meeting to
formulate a 15 year plan of action concerning “Safe Motherhood”. The
program of action discussed in the meeting included legalizing abortion,
and also increasing community awareness about safe abortion.

14. ACTION UNDERTAKEN TO INITIATE
SAFE ABORTION CARE (3/5)
• In February 2002, the Abortion Task Force (ATF) was formed by the
FHD, of the department of Health Services to plan and implement the
steps to move from legalization of action.
• The ATF assisted the FHD/DHOS in drafting and finalizing the policy
guidance and the safe abortion procedural order. It also directed to form
a team for developing medical standards and the implementation plan.
ATF was dissolved after completion of its terms in December 2003.

15. ACTION UNDERTAKEN TO INITIATE SAFE
ABORTION CARE (4/5)
• New technical committee- Technical Committee for implementation of
Comprehensive Abortion Care (TCIC) was formed in February 2003 to
support the implementation of the Comprehensive Abortion Care (CAC).
• House of Representation takes up and passes the bill on 14 March 2002.
The Bill receives Royal Assent and becomes law on 6 September 2002. The
law grants women’s rights to control over and decide on their unintended
pregnancies.

16. ACTION UNDERTAKEN TO INITIATE SAFE
ABORTION CARE (5/5)
• MOHP developed a strategic Plan for Second Trimester Abortion based on
global experiences and evidence. Finally MOHP endorsed the plan in April
2007 led to implementation of second-trimester services.
• After legalization of abortion in Nepal, government, private and
community hospitals international organizations and local NGOs like
IPAS, Marie Stopes International, Family Planning Association of Nepal,
and other clinics are providing abortion services in Nepal. Currently
abortion service is available in 75 districts of Nepal.

17. INCREASING TREND OF ABORTION
SERVICES IN NEPAL
• MOHP began providing comprehensive Abortion care (CAC) services in
2004. since then about 500000 women and had received safe and legal CAC
services through listed facilities.
• There were 10,561 abortion cases recorded in FY 2004/2005
• After 3 years, the number of abortion cases increased about 8 folds (97,378
cases in FY 2007/08) and slightly decreased thereafter.

18. • In the FY 2010/2011 total 95,305 women received abortion services.
• An estimated 323,000 abortion were performed in Nepal in 2014.

19. COMPREHENSIVE ABORTION CARE (CAC)
• Comprehensive abortion care (CAC) is an approach of providing
abortion care services that address various factors of the women’s health
needs physical, mental and personal circumstances as well as her ability
to access the service.

20. • Thus comprehensive abortion care (CAC) includes affordable and
accessible abortion care and other reproductive health service e.g.
counselling and informed consent for the termination of pregnancy,
informed choice for the post abortion family planning, identification
and treatment of sexually transmitted infections/reproductive
infections.

21. OBJECTIVES OF CAC (1/2)
• To prevent unwanted pregnancies through family planning services, including
counselling and method provision.
• To help women make free and informed decisions regarding their pregnancy,
be more informed about health services and follow up care needed and feel
more emotionally comfortable with their decisions through supportive,
nondirective reproductive health counselling.
• To ensure that the abortion service provided to women, as permitted by law,
are safe, affordable and accessible.

22. OBJECTIVES OF CAC (2/2)
• To reduce death and disability from abortion complications through
effective management and/or stabilization and referrals.
• To improve women’s broader reproductive health by integrating abortion
services into other sexual and reproductive health services.
• After the client has made a decision to terminate the pregnancy, the
service should be provided as soon as practical.

23. Guiding principles for the implementation of
CAC services
• The guiding principles on how the services should be implemented in
order to ensure women’s access to comprehensive abortion care are as
follows:
a. General principles:
• Each client has the right to access abortion care as an integral part of
comprehensive, integrated reproductive health services.
• A good history must be taken from each client.

24. • Each client must be evaluated as an individual based on her own
circumstances.
• Pre and post counselling are integral components of comprehensive
abortion care. Compassionate, non-directive pregnancy options and
abortion counselling will help women make the best decision for
themselves.

25. • Each client has right to privacy and confidentiality .
• Clients should be provided with post abortion family planning counselling and
methods that are acceptance to them.
b. Rape:
• Legal evidence of defilement, rape or incest is not required in order for the
client to obtain an abortion. (A client word is sufficient). Service providers
should take a comprehensive history and do a thorough examination including
any necessary laboratory investigations to aid any investigation that may arise.

26. C. Mental Health:
• A continuing pregnancy may put a client’s mental health at risk. Mental
health is essential to personal welfare, family and interpersonal relationships
and the individual’s contributions to the community or society.
 No psychiatric assessment is required in order to obtain a legal abortion.
 The service provider should determine the client’s emotional status in
relationship to the pregnancy. A women’s social circumstances may be taken
into account in assessing the current and future risks to her mental health.

27. d. Consent:
Minors: A minor is a person below the age 18 years
• The service provider should encourage minors to consult a parent or a
trusted adult if they have not done so already, provided that doing so will not
put the minor in danger of physical or emotional harm. However, abortion
services shall not be denied because such minor chooses not to consult them.
• A parent, next of kin, another adult or trained service provider acting in loco
parents (in place of the parent) can give consent on behalf of the minor.

28. • The confidentiality of the minor should be respected, subject to the usual
exceptions that apply to patient-provider confidentiality.
• Providers should recognize that, in cases where pregnancy occurs in a
minor under 16 years of age and is a result of defilement (statutory rape),
such patients are entitled to abortion services.

29. Others:
If a clients suffering from mental illness lacks the capacity to give consent for the
procedure, such consent should be given on her behalf by the person with legal
responsibility (her next of kin, parents, or person acting in loco parents).
e. Professional and Ethical Responsibilities:
The subject of induced abortion generates many conflicts of opinion based on
religious and other beliefs. Though individuals have a right to their own beliefs and
moral perspectives on abortion, their personal beliefs should not hinder access to
care for others.

30. Health care administrators, providers and worker must note the following:
• Service providers are mandated to provide compassionate and non-directive
counselling, factually correct information about client’s right to abortion care
and provide or refer for services.
• No providers has the right to refuse to perform an abortion procedure that is
needed to preserve a women’s health of life.
• No provider may refuse if the client is below 18 years of age, according to
the following constitutional Provisionals:

31. “(4) No child shall be deprived by any other person of medical treatment,
education or any other social and economic benefit by reason only of
religious or other beliefs.
• A service provider has a duty to provide compassionate and non-
judgmental counselling and factually correct information to the client
about her rights to the service and or refer her to an accessible provider.

32. f. Counselling:
Counselling is an integral part of service provision that must occur
throughout the service delivery process.
• All options should be presented to the client during the counselling
process.
• Sufficient and accurate information should be given to a client to support
her in making a free and informed choice.

33. • Information should be communicated in simple language understandable to
the client.
• Counselling should be provided in a conducive and enabling environment.
• Providers should focus on the needs and decisions of the client.
• Providers should not impose their own values and beliefs on the client.

34. POST ABORTION CARE (PAC)
• Post abortion care is one of important element of safe motherhood program to
reduce the risk of long term illness or disability and death of women due to
incomplete abortion.
• Post abortion care is the given to a women who has had an unsafe, spontaneous or
legally induced abortion. It consist of the following.
- Family planning counselling and services.
- Access to comprehensive reproductive health care, including screening and
treatment for STI, RTIs and HIV/AIDS.
- Community education to improve reproductive health and reduced the need for
abortion.

35. ELEMENTS OF POST ABORTION CARE
• Counselling and client provider interaction.
• Quality of service provided (treatment of incomplete and unsafe abortion
and complication)
• Post abortion contraceptive and family planning services.
• Reproductive and other health services.
• Community and service provider partnership and mobilization of
community resources.
• Prevention of unwanted pregnancy and unsafe abortion.

36. MANAGEMENT OF PAC
• Post abortion care, is important first to manage the immediate situation,
i.e., deal with bleeding and shock. Once this women’s condition is stable
it is then equally important to provide the essential follow up care,
including pain relief, psychological support, post abortion counselling
and any further tests that may be required.

37. A. MANAGEMENT OF SHOCK (1/3)
• Make sure that the airway is open.
• Check vital signs.
• Do not give fluid by mouth as the women may vomit and inhale or
aspirate the vomits.
• Keep the women warm but do not over heat.
• Maintain circulation to vital organs by elevating the legs.
• If oxygen is available, give by mask or nasal cannula at 6-8 liters per
minutes.

38. A. MANAGEMENT OF SHOCK (2/3)
• possible collect blood sample for hemoglobin and hematocrit, and cross
match.
• Start iv fluid immediately, sodium lactate or normal saline 1L in 15-20
min (normally its takes approximately 1-3 liters, infused at this rate to
stabilized a patient in shock)
• Blood transfusion is required if hemoglobin is 5g/100ml or less or
hematocrit 15% or less.

39. A. MANAGEMENT OF SHOCK (3/3)
• Medication: antibiotics should start either IV or IM.
• TT should be given if there is any uncertainty about the women
vaccination history.
• Identify cause of shock and manage accordingly.

40. MANAGEMENT OF HEMORRHAGE(1/4)
• Management should includes the following steps:
1. Management of shock.
2. Identification of bleeding site. Possible sites of vaginal bleeding includes
placenta site due to retained product of conception, cervical or genital tract,
laceration, and intra-abdominal injury.
3. Uterine evacuation.

41. MANAGEMENT OF HEMORRHAGE(2/4)
• If retained product of conception are the cause of bleeding, the uterus
must be evacuated in order to stop bleeding.
• The technique for uterine evacuating used in abortion care in the first
trimester are as follows:
- Manual vacuum aspiration.
- Dilatation and curettage if manual vacuum aspiration is not available.

42. MANAGEMENT OF HEMORRHAGE(3/4)
4. Examination of the products of conceptions:
The tissue removed from the uterus must be examined immediately following the
evacuation procedure.
Finding:
• The presence of decidua without villi may indicate incomplete evacuation of
uterus, ectopic pregnancy complete abortion prior to procedure.
• Old blood clots, pus or foul smelling, indicate infection/sepsis.
• Grape like clusters indicate the possibility of a molar pregnancy or hydatidiform
mole.

43. MANAGEMENT OF HEMORRHAGE(4/4)
5. Repair of cervical or genital tract lacerations
6. Managing of uterine perforation:
• The uterine perforation is suspected after an unsafe abortion, appropriate steps that
may be taken include observation with readiness to explore, laparotomy and repair
-start IV fluids
-Observation of bleeding and the women’s general condition such as vital signs,
pallor, consciousness and urine output etc.
7. Referral and transfer.

44. MANAGEMENT OF INTRAABDOMINAL
INJURY
• Any injury to internal organs, if not readily diagnosed and treated, Can lead to
serious and irreversible consequences including bleeding, infection and death.
Therefore, whenever a women is treated for complications following an unsafe
abortion, the possibility of a genital tract injury should be considered.
• The common injuries seen are uterine perforation and cervical lacerations. Damage
to the ovaries, fallopian tubes, bladder, bowel and rectum can be occur.

45. MANAGEMENT OF SEPSIS (1/3)
• If the infection has been spread beyond the uterus or if septicemia is
suspected, management should be as follows:
• Management of shock
• Identification of source of infection
• Choice of antibiotics:
 If severe infection involving deep tissue, give ampicillin 2g IV stat every
6 hours and gentamycin 5mg/kg body weight IV every 24 hours and
metronidazole 500mg IV every 8 hours.

46. MANAGEMENT OF SEPSIS (2/3)
 If infection does not involve deep tissue give amoxicillin 500mg orally 3
times a day for 5 days and metronidazole 400mg orally 3 times a day for
5 days. Gentamycin 5 mg/kg body weight IV every 24 hours for 5days.
• Tetanus immunoprophylaxis:
 If women has been fully immunized for tetanus within the last 10 years
and has a clean, minor wound, no immunoprophylaxis is required.

47. MANAGEMENT OF SEPSIS (3/3)
• Uterine evacuation: if retained products of conception are cause of
infection, the uterus should be evacuated, preferably using MVA.
• Examination of the products of conception.

48. INFORMATION COUNSELLING AND
COMMUNICATION (1/3)
• Information about condition and treatment except in the most extreme medical
emergencies, patient should be informed about their condition and proposed
treatment, before the treatment begins.
• Post operative information:
- Before the women is discharged, she should be informed about the normal
progress of recovery and be given recommendation about normal activity.

49. INFORMATION COUNSELLING AND
COMMUNICATION (2/3)
- In addition to be informed about the signs of possible complications and
where to seek help should these become apparent and the early return to
fertility.
- She should also receive post abortions family planning, counselling and
advice. Appropriate advice and counselling for screening for STI, RTI and
HIV.

50. INFORMATION COUNSELLING AND
COMMUNICATION (3/3)
• Family planning counselling:
 Ovulation can occur as early as two or four week after an abortion.
 Approximately 75% of women who have had an abortion will ovulate
within six weeks of abortion.
 After a first trimester abortion, ovulation often occurs within two weeks,
and after a second trimester abortion, within four weeks.
 Therefore, there is an immediate need for contraceptive for women who do
not want to become pregnant or for health.

51. MANUAL VACUUM ASPIRATION (MVA)
• Manual vacuum aspiration (MVA) is an effective method for treatment of
incomplete abortion by removing the contents of uterus with suction.
Indication:
• Early pregnancy loss.
• Incomplete abortion
• Termination of early pregnancy for indications within the law.
• Completion of evacuation of retained products in incomplete evacuation
medical treatment.

52. Contraindication:
• Should not use MVA beyond 15 weeks of gestation.
Cautions:
However it should be used with caution in women who have:
• Uterine anomalies.
• Coagulation problems .
• Any condition causing the patient to be medically unstable.

53. EQUIPMENT REQUIRED
• MVA aspirator
o Manual:
 Hand held vacuum syringe with a flexible syringe
 Foot pump vacuum.
o Electrical vacuum.
• Silicone lubricant
• Cannula
• Adaptor for cannula.

54. • Specula
• Tenaculum (sharp-toothed or traumatic)
• Ring forceps
• Antiseptic solution, gauze, and small bowl.
• Mechanical dilators
• Syringe, needle, and anesthetic agent for cervical block.

55. PREVENTION OF INFECTION
• Use of no-touch technique and prophylactic antibiotics can help to avoid
infection. The first dose should ideally be administered 30 minutes
before the procedure. One regimen often quoted in the medical literature
is azithromycin 1g, and metronidazole 400mg one hour before the
procedure and 200 mg 30 minutes afterwards.

56. PROCEDURE
• Give oxytocin 10 units IM or Ergometrine 0.2 mg IM before the
procedure to make the myometrium firmer and reduce the risk of
perforation.
• Perform bimanual pelvic examination, checking the size and position of
uterus, degree of cervical dilatation and the condition of the fornics.
• Insert speculum and remove blood or tissue from the vagina using
sponge forceps and gauze.

57. • Apply antiseptic solution to cervix and vagina using gauze or cotton.
• Check the cervix for tears or protruding products of conception. If products
of conception are present in the vagina or cervix. Remove them using ring or
sponge forceps.
• While gently applying traction to the cervix, insert the cannula (gently and
slowly) through the cervix into the uterine cavity until it just touches the
fundus (not more than 10cm). Then withdraw the cannula slightly (about
1cm) away from the fundus.

58. • Gently grasp the anterior or posterior lip of the cervix with a vulsellum
or single toothed tenaculum.
• Inject 1 ml of o.5% lignocaine solution into the anterior or posterior lip
of the cervix which has been exposed by the speculum.
• Gently apply traction on the cervix to straighten the cervical canal and
uterine cannula.

59. • Attach the prepared syringe to the cannula by holding the cannula in one
hand and the tenaculum and syringe in the other. Make sure cannula does
not move forward as the syringe is attached.
• Release the pinch valves on the syringe to transfer the vacuum through the
cannula to the uterine cavity.
• Evacuate remaining uterine contents by gently rotating the syringe from side
to side and then moving cannula gently and slowly back and forth within the
uterine cavity.

60. • If the syringe becomes half full before the procedure is complete, detach
the cannula from the syringe, remove only the syringe, leaving the
cannula in place.
• Push the plunger to empty POC (Products of conception) into the
strainer.
• Recharge syringe, attach to cannula and release pinch valve. Ensure that
vacuum is not lost in the syringe.

61. • Check for signs of completion of the procedure (red or pink foam but no
more tissue is seen in the cannula, grating sensation is felt as the cannula
passes over the surface of the evacuated uterus; uterus contracts around
the cannula).
• Withdraw the cannula and MVA syringe gently.
• Remove tenaculum or forceps from the cervix before removing the
speculum. Remove the speculum.

62. • Perform bimanual examination to check the size and firmness of the uterus.
• Quickly inspect the tissue removed from the uterus (and presence of products
of conception), assure complete evacuation, check for a molar pregnancy
(rare).
If necessary, rinse the tissue or remove excess blood clots, then place in a
container of clean water or saline or weak acetic acid (vinegar) to examine.
If no POC are seen, reassess situation to be sure it is not an ectopic
pregnancy.

63. • Gently insert speculum and check for bleeding.
• If uterus is still soft or bleeding persists repeat the evacuation.

64. POST PROCEDURE PATIENT MONITORING
• After the procedure, the patient should be monitored for signs of pain
and bleeding. A clinician should be notified in the event of fever or
prolonged, worsening, or severe pain or bleeding.

65. POST-OPERATIVE TISSUE EXAMINATION
• It is critical to examine the products of conception (POC) after completion of the
procedure. A common technique for early tissue examination includes the following
steps:
o Wash the aspirate in a fine-mesh metal strainer under running water to remove
blood and clots.
o Transfer the remaining tissue into a clear glass dish containing about 0.5 inch of
water or saline solution.
o Place the dish on a radiograph box or photographic slide viewer, as back lightening
greatly facilitates differentiation of the pregnancy elements.

66. • Additional issues regarding tissue identification:
o A women experiencing early pregnancy loss (i.e. miscarriage) may have already
expelled the pregnancy and thus only limited tissue may be present.
o POC from a very early pregnancy (<6weeks) may be difficult to identify without
specialized training.
o MVA may be unsuccessful when an abnormality in uterine shape is present, when it
makes the cannula placement difficult or impossible. In such cases, the patient will
need another option for her management such as traditional D&E.

67. COMPLICATION OF MVA
• Incomplete evacuation.
• Uterine perforation.
• Cervical laceration
• Pelvic infection
• Hemorrhage
• shock
• Air embolism

68. LEGALASPECT OF ABORTION IN NEPAL
As amended by the legal code grants the right to termination of pregnancy to
all women without regard to their past or present mental status, on the
following conditions (Family health division and National Health Training
Center, Comprehensive Abortion Care, Training Manual, 2007):
• Up to 12 weeks of gestation for any indications with the request of the
pregnant women.
• Up to 18 weeks of gestation in the case of rape or incest with request of the
pregnant women.
• At any gestation , if the pregnancy is harmful to the pregnant woman’s
physical or mental health, as certified by an expert physician.

69. Acc. to 2017 laws of abortion
• Up to 12 weeks of gestation for any indications with the request of the
pregnant women.
• Up to 18 weeks of gestation in the case of rape or incest with request of
the pregnant women.
• At any gestation , if the pregnancy is harmful to the pregnant woman’s
physical or mental health, as certified by an expert physician.

70. Additional considerations:
• Only certified medical practitioners (Health service providers) in safe
abortion care eligible to provide Comprehensive Abortion Care services.
• Only the pregnant women holds the right to choose to continue or
discontinue the pregnancy. If the pregnant women is a minor (less than
16years of age) or not in a position to give consent (mentally
incompetent), the nearest guardian or relative can give consent for
abortion services.

71. • The law prohibited termination of pregnancy of any gestation for the sole
purpose of sex selection.
• Anyone found guilty of conducting or causing to be conducted such an
amniocentesis test is to be punished with imprisonment of 3-6months.
• Anyone found guilty of performing or causing to be performed an
abortion on the basis of sex selection is to be punished with one
additional year of imprisonment.

72. • The regulation specify that for pregnancy up to 12 weeks Manual
Vacuum Aspiration (MVA) can be used, while beyond 12, MVA and
dilation and evacuation (D&E) can be used.
• A health care institution or provider wishing to provide abortion needs to
be registered with the Ministry of Health’s Department of Health
Services.
• Provider or institution are permitted to charge for the cost of pregnancy
termination, but are required to maintain transparency about price.

73. REFERENCES
• Dirgha Raj Shrestha, 2nd edition, Reproductive health National and
International Perspectives. Page no:270-278
• www. Public health in Nepal.blogspot.com
• https://www.dhsprogram.com/pubs/p
• National guidelines of post abortion care.
• www.srhr.org