CORE COMPETENCIES FOR EARLY ABORTION CARE

BY PRIMARY CARE CLINICIANS:

FIRST TRIMESTER ASPIRATION ABORTION

 

Primary, secondary and tertiary prevention of unintended pregnancy (Taylor 2011) is an essential element of sexual and reproductive health care, a specialty of primary medical care and public health services. Early abortion care is considered one component of secondary prevention of unintended pregnancy.

This document describes the entry-level specialty competencies for primary care clinicians providing early abortion care, regardless of setting. These specialty competencies are the essential knowledge, behaviors, and skills that primary care clinicians should be able to demonstrate upon application for practice in abortion care and secondary prevention of unintended pregnancy. They are intended to supplement the health-professional core competencies for primary-care clinicians (e.g. CNM, DO, MD, NP, PA) as well as population-focused competencies (e.g. women’s health care, family practice) (Informed by HWPP 171, TEACH 2012 , and UK SRH 2012 Curricula).

 

I. Competence Level Descriptors: Measurement of achievement and progression

Competence is a baseline level for safe independent practice, with further (post-training) exposure and experience leading to proficiency and subsequent expertise. Attainment and assessment of any competency should progress through all three of the following stages.

Level 1 (observation or indirect methods)

  • Demonstrate thorough understanding of the principles of the competency/clinical skill/situation, including the indication for the procedure and common complications
  • Observe the procedure on a number of occasions before direct supervision of clinical skill
    Use other methodologies (e.g. drills, simulation, e-learning, case-based discussion assessments) if direct experience is not possible

Level 2 (direct supervision across different clinical situations)

  • Perform the clinical skill/manage case under supervision
    The number of times the competency/clinical skill/situation needs to be supervised depends on the complexity of the case and individual aptitude
  • No limit to the number of times the procedure can be supervised; both trainee and trainer must be certain that the procedure can be safely performed in a number of different clinical situations and levels of complexity
  • Be able to manage any unexpected complication and know when to summon senior help

Level 3 (independent practice)

  • Ability and confidence to perform the clinical skill/situation competently when senior staff is not immediately available
  • Willingness to move on to experiential learning with further case exposure
    Keep a record of the numbers of cases/procedures subsequently managed (including any complications and their resolution)

II. Specific competencies to be attained

Pre-requisite to training: Unintended Pregnancy Care Competencies

  • Perform comprehensive pregnancy options counseling and care coordination (for adoption, prenatal care, abortion)
  • Effectively communicate with patients and accompanying persons, respecting diversity of beliefs
  • Effectively counsel the psychosocially complex patient (e.g. ambivalence, mental health conditions, religious belief conflicts)
  • Perform pregnancy test, including appropriate type (urine v. serum), interpret results and deliver results neutrally
    • If positive, calculate estimated gestational age and discuss pregnancy options in an unbiased, non- directional manner
  • If patient indicates desire to continue: Initiate antenatal/adoption care pathways/clinical guidelines
  • If patient indicates desire to terminate: Initiate abortion care pathways/clinical guidelines
  • Assess and manage identified clinical and non-clinical risks
  • Perform STI risk assessment and manage positive responses appropriately by performing relevant screening, providing risk reduction counseling and referrals as necessary
  • Provide contraceptive education and counseling and provide selected method, or refer, as appropriate
  • Provide supportive counseling and education (written, verbal, electronic) to promote closure of encounter, including follow-up & care coordination or referral

Pre-Procedure Assessment Competencies

  • Perform pre-abortion clinical history including complete medical, reproductive and sexual and social history and risk assessment
  • Manage positive responses appropriately by providing necessary screenings, counseling and referrals and partner notification if positive STI screening results
  • Perform appropriate clinical examination including assessment of gestation
    • Arrange/perform laboratory and ultrasound investigations, and specific investigations as prompted by history and examination
    • Conduct assessment to determine/confirm gestational age (ultrasound for pregnancy elements, bimanual exam for uterine size)
  • Manage unexpected findings from routine assessment as per clinical guidelines (e.g. miscarriage, ectopic gestation, molar pregnancy
  • Communicate effectively with patients and accompanying persons they wish to have present
    • Explain clearly and without bias—treatment regimens, potential side effects of drugs and complications of procedures
    • Demonstrate consistent respect for diversity of beliefs and values
    • Counsel the psychosocially complex patient (e.g. ambivalence, mental health conditions, family conflicts) and engage other health professionals as needed (e.g. therapist, social worker) to ensure effective communication and management plan
  • Arrange abortion procedure or refer to another agency, including cervical priming and follow-up as necessary
    • Arrange interpreter/signer if required
  • Prescribe drugs required for chosen procedure including cervical priming/local antibiotic prophylaxis policy/contraception as per clinical guidelines
  • Formulate, implement and, if necessary, modify management plans in consultation with patient
  • Complete documentation including consent
    • Seek informed consent after assessment of cognitive competency
    • Document episode accurately
  • Provide contraceptive and sexual health advice and supplies

First-Trimester Aspiration Abortion Procedure Competencies

To 14 weeks, by manual vacuum aspiration (MVA) or electric vacuum aspiration (EVA)

  • Verify absence of changes in health
  • Confirm consent for procedure and post-abortion contraceptive plan choice since pre-procedure assessment
  • Confirm all medications prescribed and administered/taken including cervical priming, antibiotics and contraception
  • Check equipment and supplies for procedure including for analgesia, sedation
  • Manage pain appropriately using local anesthesia and analgesia
  • Manage pain using moderate/conscious sedation – optional depending on institutional guidelines
  • Complete abortion procedure by MVA and/or EVA
    • Position patient
    • Use ‘no-touch’ clean technique throughout procedure
    • Perform:
      • Bimanual examination (empty bladder)
      • Speculum examination
      • Stabilization of cervix
      • Application of local anesthetic to cervix
      • Cervical dilation
      • Aspiration of uterine contents
      • Use of ultrasound during the aspiration procedure
      • Gross identification of products of conception and disposal of same with due regard to respect and dignity
    • Manage if inadequate products of conception (i.e. incomplete or failed abortion, rule out ectopic or molar pregnancy)
    • Manage immediate complications including: dilation difficulties, poor aspiration of uterine contents, blockage of cannula, excessive bleeding/hemorrhage, uterine atony, incomplete abortion, continuing pregnancy, vasovagal reaction, allergic reaction, uterine false passage/perforation, cervical laceration, air embolism, acute hematometra
    • Provide immediate post-abortion contraception (including IUDs, implants, DMPA)

Post-Procedure Assessment and Follow-up Competencies

  • Perform immediate post-procedure clinical assessment and routine follow-up.
    • Conduct investigations with ultrasound and/or laboratory assessments to confirm resolution of pregnancy (e.g. beta HCG, hemoglobin) as necessary
  • Confirm procedure complete by gross or additional examination of uterine contents (i.e. products of conception examination) by identifying pregnancy elements consistently and accurately
  • Assess physical and psychological wellbeing of patient; review counseling and support needs
  • Review needs for social support and assistance following procedure with special attention to patients with particular vulnerability (e.g. minors; those with psychiatric conditions/mood disorders, limited social support, or high risk for intimate partner violence, repeat unintended pregnancy or STI)
  • Contact patient after discharge to assess problems and/or to determine return to primary prevention methods of unintended pregnancy or reproductive life plan
  • Manage delayed complications including bleeding, infection, retained products of conception, ongoing pregnancy, and emotional distress
  • Complete documentation

 

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