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Practical Nursing Management of Abortion: Experiences in Sub-Saharan Africa

By Christopher Oseh, MBBS

Sarah’s mother rushed her to a nearby health center after a sudden onset of dizziness and weakness which accompanied persistent vaginal bleeding, and lower abdominal cramps in the last 24 hours. The doctor was off duty and Sarah was under the care of the nurse on night duty.

The nurse immediately set up an intravenous line, took a brief history, deferred vaginal examination, and requested a pregnancy test based on the clinical history. After evaluating Sarah together with a positive pregnancy test, the nurse suspected a threatened miscarriage. She counselled Sarah for admission and bed rest. The following morning, the doctor re-assessed Sarah after a pelvic ultrasound scan showed features of a threatened miscarriage.

Sarah’s life and her fetus were saved because a nurse was knowledgeable about how to manage a suspected abortion.

Why did the nurse defer vaginal examination?
Was her approach correct?

In this article, you will learn the role of nurses in the care and management of abortion.

What is abortion?

Abortion is the expulsion of a fetus less than 500g and the product of conception before the age of fetal viability, which is 28 weeks of gestation in sub-Saharan Africa. An abortion may be induced or spontaneous. Induced abortion is an artificial termination of pregnancy, while a spontaneous abortion (or miscarriage) is a natural or unprovoked pregnancy loss.

Types of spontaneous abortion

Spontaneous abortion is divided into various types depending on the clinical history and pelvic ultrasound scan findings.

  • Threatened abortion
    This is characterized by lower abdominal cramps, brownish vaginal bleeding, ultrasound showing a closed cervical external os, and a viable fetus.  Inevitable abortion In addition to vaginal bleeding with cramps, the diagnostic finding is the presence of an open external os with a fetus that may be viable or not.
  • Incomplete abortion
    Here, there is a history of expelling products of conception together with vaginal bleeding and cramps. However, a pelvic scan shows some retained products of conception and a non-viable fetus.
  • Complete abortion
    The patient complains of intermittent lower abdominal pain and vaginal bleeding with the passage of products of conception. A pelvic scan reveals an empty uterus with an open or closed external cervical os.

Management of abortion

The management of abortion considers the combination of the history, examination findings, and investigation results. Each country has its abortion law and the role of nurses in post-abortion care.

For example, in Nigeria, trained nurses and midwives can perform post-abortion care. In contrast, only qualified midwives have the legal authority to perform post-abortion care in Ghana, and in Kenya, post-abortion care is currently only performed by physicians. However, in Mozambique maternal-child nurses can legally provide comprehensive care including ultrasound, administration of misoprostol, manual vacuum aspiration, follow-up, and post-abortion care.

History

Abortion is one of the possible diagnoses in a female within the reproductive age group (16-49 years) who presents with the following symptoms:

  • Lower abdominal cramps
  • Missed menstrual period
  • Vaginal spotting
  • Vaginal bleeding

Examination

Speculum or manual vagina exam must be deferred until a pelvic scan confirms abortion and fetal viability. Conducting a vagina or speculum examination in a woman with threatened miscarriage may lead to inevitable abortion.

Investigation

  • Pregnancy test: Confirms if the patient is pregnant and if the vaginal bleeding is related to early pregnancy complications such as abortion.
  • Pelvic ultrasound scan: The definitive diagnostic test that confirms fetal variability and the type of abortive process.
  • Packed cell volume: Recommended for patients with severe vaginal bleeding to rule out severe anaemia and ascertain the need for blood transfusion.

Treatment

The options are:

  • Medical
  • Surgical

Medical treatment

This involves using drugs to either support the fetus or strengthen the uterine contraction to expel retained products of conception, as seen in incomplete abortion.

Supportive drugs are mainly progesterone tablets or injections used to promote the implantation of the fetus into the uterus. In contrast, in incomplete abortion, an oxytocic drug such as misoprostol increases uterine contraction to expel any remaining products of conception in the uterus. Ideally, a doctor prescribes these drugs or supervises their administration.

Surgical treatment

Indicated for inevitable abortion, fetal death failed medical treatment for incomplete abortion or a significant amount of retained products that must be manually expelled. Due to the low risk of obstetric complications, manual vacuum aspiration is the procedure of choice for evacuating large retained products of conception for an abortion that occurs before 13 weeks of gestation.

In some countries, it is performed mainly by doctors, while in some other countries, a trained nurse or midwife can perform the procedure under supervision if necessary. Manual vacuum aspiration involves using a long vacuum tube inserted into the uterus to empty the uterine content using gentle suction pressure after dilating the cervix and administering a local anesthetic to relieve pains. The procedure is safe, effective, and short.

Here are general nursing care for abortion:

  • Continuous monitoring of vital signs for patients with severe vaginal bleeding.
  • Inserting a vagina pad to monitor the degree of vaginal bleeding
  • Intravenous fluids administration
  • Administration of oral drugs and injections

Final thoughts

Nurses are critical to managing patients with abortions, and their level of knowledge and skill can influence the outcome of an abortion. Abortion is a diagnosis of exclusion which means other possible causes must be excluded using specific investigations outlined above. The role of nurses in carrying out surgical therapeutic interventions for abortion depends on the local abortion laws so nurses are to stay updated with their country’s abortion legislation.

Dr. Christopher Oseh is an experienced primary care physician, health blogger, content marketing professional, and self-published author. He specializes in creating content for health care providers and health technology companies.

To learn more about nurses’ roles in abortion care click here and here.

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