Other residency programs are less codified, but teach residents technical aspects through their management of early spontaneous abortions and pregnancy interruption for fetal death, severe fetal anomalies, and life-threatening medical or surgical disorders.
he College (2016g) respects the need and responsibility of health-care providers to determine their individual positions on induced abortion. It also advocates for counseling and timely referral if providers have individual beliefs that preclude pregnancy termination. hree basic choices available to a woman considering an abortion are: (1) continued pregnancy with its risks and parental responsibilities; (2) continued pregnancy with arranged adoption; or (3) termination of pregnancy with its risks. Knowledgeable and compassionate counseling should objectively describe and provide information regarding these choices to permit informed decision-making (Templeton, 2011).
Pregnancy termination can be performed either medically or surgically by several methods. In the absence of serious maternal medical disorders, abortion procedures do not require hospitalization (Guiahi, 2012). However, outpatient surgical facilities should have the ability to provide emergency resuscitation and immediate transfer to a hospital (American College of Obstetricians and Gynecologists, 20 14b).
Surgical evacuation is performed transvaginally through an appropriately dilated cervix. For this, preoperative cervical ripening is favored by many and is typically associated with less manual intraoperative cervical dilation, a technically easier procedure, less pain, and shorter operative times (Kapp, 2010; Webber, 2015). On balance, cervical preparation adds a surgical delay and potential side efects. In a selective approach, some recommend cervical priming for irst-trimester suction curettage only for those at greater risk of complications from intraoperative cervical dilation, such as those with cervical stenosis and adolescents (Allen, 2016). Of note, surgical steps presented here apply to both induced abortion and miscarriage, discussed earlier (p. 347).
FIGURE 18-5 Hygroscopic dilators. With each type, the dry unit (left) expands exponentially when exposed to water (right) as in the endocervical canal. A. Laminaria. B. Dilapan-S.
For ripening, hygroscopic dilators, also called osmotic dilators, are devices that draw water from surrounding tissues and expand to gradually dilate the endocervical canal. One type is derived from various species of Laminaria algae that are harvested from the ocean floor (Fig. 18-5). hese come in diferent diameters, which allow the number of inserted devices, also called tents, to be customized to a given cervix. Another device is Dilapan-S, which is composed of an acrylic-based gel. Each type expands to an ultimate diameter three to four times that of its dry state. However, Dilapan-S achieves this in 4 to 6 hours, which is faster than the 12 to 24 hours needed for laminaria (Fox, 2014).
With hygroscopic dilators, shallow insertion yields insuicient internal os dilation or tent expulsion, but deep placement risks dislodgement into the uterine cavity (Fig. 18-6). Accordingly, the numbers of sponges and dilators inserted are carefully counted and recorded in the patient's chart. Once tents are inserted, several gauze sponges at the external os help prevent spontaneous tent expulsion. Patients can ambulate, void, or stool without limitation.
FIGURE 18-6 Insertion of laminaria before dilatation and curettage. A. Laminaria immediately after being appropriately placed with its upper end just through the internal os. B. Several hours later the laminaria is now swollen, and the cervix is dilated and softened.
C. Laminaria inserted too far through the internal os; the laminaria may rupture the membranes.