COUNSELING DURING THE PROCEDURE

ESTABLISHING RAPPORT AND RESPONDING TO PATIENTS

A friendly introduction and taking a seat demonstrates respect and helps ease anxiety that typically occurs prior to a procedure. These conversations are best held with you sitting at the patient’s level, with them sitting up. It is a good time to discuss questions and relaxation techniques. Use your intuition as to what will be most helpful: sometimes quiet, sometimes humor, and sometimes talking about work, kids, school or goals will resonate well with a patient.

HELPFUL TECHNIQUES DURING THE PROCEDURE

  • Use description, distraction, and breathing techniques discussed in Chapter 4.
  • Use supportive statements, such as “Everything is going really well” or “You are doing a good job relaxing your bottom into the table.
  • Alert the patient to what they might feel to avoid alarming them. It can also be helpful to say, “We’re about two thirds through” or “This part takes about one minute.”
  • Check in about whether they want physical and / or emotional support during the procedure, offering an assistant’s reassurance or hand to squeeze.
  • Take breaks during natural pauses in the procedure, saying something like “We have a break right now. You can take some slow deep breaths.”
  • If the patient asks to stop, do so adding “Do you need a break now? Let’s try taking some deep breaths, and let me know when you are ready to proceed.”
  • Gentle firm directions given in a kind, steady tone may be appropriate for a patient who is very upset and unable to hold still, to help them regain control.
  • Continue to communicate with a quiet or silent patient at regular intervals throughout the procedure. It can help to ask how the patient is doing.
  • Offer patients to have a support person there if possible, such as a partner, friend, family member, or trained doula. Those receiving doula support are less likely to require additional clinic support resources, although pain and satisfaction are unchanged (Chor 2015). Where possible, encourage institutional policies allowing presence of a support person.

When is it appropriate to defer an abortion?

Some patients feel a new sense of ambivalence immediately before the procedure begins. This may be another way a patient communicates heightened fear, or it may be that the reality of being in the procedure room is making the patient reconsider their decision.
It is not appropriate to try to facilitate a decision-making process while the patient is sitting, undressed, on the table. They should be offered supportive counseling and more time to think.
In deciding how to proceed, it is appropriate to trust your instincts. Some patients, who may be having difficulty accepting responsibility for their decision, recant in an effort to make the provider or the agency “responsible”. In such a case, the provider must ask for a clear statement of the patient’s intent before proceeding. For example:

I’m not sure if you are ready to go on with the procedure today. If you are not sure, we can postpone. Do you need some more time?”

For many patients, this last moment is what they need; when faced with the possibility of NOT going forward, the other option is less appealing, and they know they want to proceed.

RESPONDING TO CHALLENGING QUESTIONS

One of the most difficult tasks is responding to tough patient questions. Here we will review some of the most common questions that arise. General guidelines are that you:

  • Remain sensitive to both verbal and non-verbal expressions of emotion
  • Acknowledge the patient’s feelings
  • Clarify the patient’s true question to avoid assumptions
  • Provide accurate information.
“What do you do with the baby after the abortion?”

The word “baby” may cause the provider to assume that the patient is feeling guilt. To avoid responding based on assumption, providers might say, “A lot of patients ask about that. Can you tell me a little more about what is concerning you?” Consider responding, “I examine the pregnancy tissue to make sure that you are no longer pregnant.” If there are follow up questions you can say the pregnancy tissue is handled like tissue from any medical procedure. Sites have different policies for handling tissue based on local and hospital policies. You could say, “We send the tissue to the pathology lab if there is any concern, and otherwise it is handled similar to cremation.”

“Can I see it?”

In first-trimester abortion, many providers explain the process of fetal development and show the patient the pregnancy tissue if asked. Consider describing what the pregnancy tissue looks like at that stage, so they can make an informed choice about seeing it.

“Will this hurt the baby?”

Evidence regarding the capacity for fetal pain indicates that fetal perception of pain is unlikely before the third trimester (Lee 2005). For patients having a first-trimester abortion procedure, explaining the facts may alleviate this concern. For example, “At this point in the pregnancy, the fetal nervous system is still not developed enough to feel pain.”

Post-Procedure Support

After the procedure, you can reassure the patient that everything went well, and offer guidance for next steps. Let them know that the cramps they are feeling are a sign that the uterus is healthy and returning to its non-pregnant size. Reassure them that emotions arising with abortion are normal, that you are there with them, and that there are various outlets and resources to support them beyond the procedure.
You can reassure them that your staff will be available to them. They can be offered a follow-up visit if desired or you think it would be helpful, especially if there is a continuity relationship.  However, it is not always indicated. (Grossman 2004).
Additional ideas: