Inga-Maj Andersson

Ponencia:

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    Care - special considerations

    Inga-Maj Andersson, Midwife MSc, Södersjukhuset AB, Stockholm, Sweden

    Background: Nursing in late abortion is a challenge that requires sensitivity and professional knowledge. The woman is in a complex situation with many aspects to consider.

    Materials and Methods: Review of the current literature and experience of encounters with women who have had late abortions.

    Results: Attitude and way of communicating security and trust are important for the woman's experience in an abortion situation. To show respect for the woman by being responsive to her story / experience may make  it easier  for the woman  (and her partner)  and for those who care to find a good path through

    the abortion.

    Women’s experience of pain varies with gestational age, maternal age and parity. By estimating the woman's pain perception and evaluate given pain treatment during the abortion gives a greater opportunity to optimal pain relief during the abortion. Systematically given opioids are not optimal treatment in pain from urogenithal region.

    Anxiety is related to pain in a number of procedures and situations. To reduce stress related to the physical and emotional aspects of the abortion information is helpful. It is important for the women to have accurate information before the procedure and high quality care throughout. The information and care should be as effective as possible in meeting the needs for the individual woman.

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    Caring for women undergoing second trimester medical termination of pregnancy

    Inga-Maj Andersson, Kristina Gemzell-Danielsson, Kyllike Christensson Karolinska Institutet, Stockholm, Sweden - inga-maj.andersson@ki.se

    Objective: To explore the experiences and perceptions of nurses/midwives caring for women undergoing second trimester medical termination of pregnancy (MTOP). Method: Semistructured interviews took place at one gynaecological clinic in a general hospital in Stockholm. Twenty-one nurses/midwives with experience in second trimester abortion care were interviewed following a semistructured interview guide. The interviews were recorded, transcribed verbatim and then analyzed using qualitative content analysis to identify common themes. Results: The analysis revealed two themes: "The professional self," with six subthemes describing the experiences and perceptions described in terms of professional behavior: "Being familiar with the process", "Balancing objective information", "Finding ways for pain treatment", "Looking for the woman's needs", "Handling the fetus" and "Needing time for reflection". The theme "The personal self" has four subthemes containing the experiences and perceptions described in terms of personal values: "Conflicting duty and behavior", "Dealing with emotions", "Identifying oneself with the woman" and "Developing inner safety and maturity". Conclusions: Taking care of women undergoing second trimester MTOP is a task that requires professional knowledge, empathy and the ability to reflect on ethical attitudes and considerations. Difficult situations that arise during the process are easier to handle with increased knowledge and experience. Mentorship from experienced colleagues and structured opportunities for reflection on ethical issues enable the nurses/midwives to develop security in their professional roles and also feel confident in their personal life situation. The feeling of supporting women's rights bridges the difficulties nurses/midwives face in caring for women undergoing second trimester MTOP.

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    Comprehensive pain treatment in abortion care
    Inga-May Andersson, Midwife Msc 
    Karolinska University Hospital, Stockholm
    Background: Pain during abortion is a complex condition with many aspects to pay
    attention to in the nursing care of women undergoing abortion. Management of pain during
    abortion has been given insufficient attention.
    Materials and Methods: Review of the current literature.
    Results: The abortion methods have been given a lot of attention in different research
    projects. Several studies focus on the regimen of medical abortion. The methods for
    surgical abortion are also well evaluated.
    Studies show that women’s experience of pain varies with gestational age, maternal age
    and parity. Visceral pain, as abortion pain belongs to, is deep and poorly localised often
    with high intensity score. Systematically given opioids are not optimal treatment in pain
    from urogenithal region; regional blockades are more effective. Early treatment of pain
    reduces the pain intensity.
    Anxiety is related to pain in a number of procedures and situations. Anxiety combined with
    physical (nociceptive) pain makes the total experience of pain more intensive. To reduce
    stress related to the physical and emotional aspects of the abortion information is helpful.
    It is important for the women to have accurate information before the procedure and high
    quality care throughout. The information and care should be as effective as possible in
    meeting the needs for the individual woman.
    Other non-medical pain management strategies should also be given the necessary
    attention. The woman should be offered a choice of abortion methods because women
    report less pain if the choice of early abortion has been their own decision. The importance 

    of positive staff attitudes and a non-judgemental atmosphere in the quality of care is
    emphasised.
    Conclusions: Pain treatment in abortion care is a complex challenge. Correct information,
    positive attitudes together witn non-judgemental atmosphere are important parts to reduce
    stress for the women. Medical pain management during abortion should be mixed with
    drugs acting both central- and periphere. Paracetamol, kodein and NSAID is
    recommended. Local anaesthetic by paracervical blockade is an effective method if
    needed. Prophylactic pain treatment should be considered.

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    Women´s experiences of second trimester medical termination of pregnancy and their feelings and thoughts about viewing the fetus

    Inga-Maj Andersson, Kristina Gemzell-Danielsson, Kyllike Christensson Karolinska Institutet, Stockholm, Sweden - inga-maj.andersson@ki.se

    Objectives: To explore women´s experiences of second trimester medical termination of pregnancy and their feelings and thoughts about viewing the fetus. Method: A cross-sectional and descriptive study using both a questionnaire and semi-structured interviews for data collection. Thirty-one women filled out the questionnaire and among them 23 women were later interviewed. The questionnaires were analyzed by descriptive statistics. The answers from the questionnaires were followed up in the interviews. The interviews were recorded, transcribed verbatim and then analyzed with qualitative content analysis to identify common themes. Results: Indication for the abortion was fetal malformation or unintended pregnancy. Independent of the reason for the abortion similar feelings were expressed by the women. After having divided the feelings into positive or negative, we found that 57 % of the women had chosen both positive and negative feelings, and 40 % of the women had chosen just negative feelings. Concerns for a suffering fetus and a curiosity of what it would look like or what kind of person it could have been were expressed. Thoughts that viewing the fetus would cause increased grief or mental weakness in the future were expressed by some women. The analysis of the interview texts revealed five themes mirroring the women´s experiences, thoughts and feelings related to the abortion: "Not knowing what to expect", "To suffer", "To manage", "To get support" and "To remember", each theme is divided into subthemes to clarify the meaning. Conclusions: Women undergoing second trimester abortion need to have time and the opportunity to reflect on their feelings and thoughts in connection with the abortion. Independent of the indication for the abortion feelings of grief and sadness are seen as well as feelings of having killed their child. It is important to listen to the woman´s individual needs and give the opportunity to view the fetus if the woman wishes regardless of the reason for the abortion.

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    Pain treatment during second trimester abortion
    Inga-Maj Andersson, K. Gemzell-Danielsson, O. Stephansson, K. Christensson,
    Dept of Woman & Child Health, Karolinska University Hospital,/Institutet
    Stockholm, Sweden,

    Objectives To assess pain intensity, methods of pain treatment and predictors for the
    need of analgesia in women undergoing second trimester abortion.
    Design Descriptive study with consecutive inclusion of patients.
    Material and methods A combined treatment with mifepristone and misoprostol was used
    for the termination of pregnancy. From February 2002 to June 2003 data from 122 women,
    undergoing second trimester abortion, was collected into a protocol to describe pain-
    intensity measured by Visual Analoge Scale (VAS) and methods of pain treatment.
    Demographic data such as age, gestational duration and reproductive history were
    collected. The indication for the termination of pregnancy was noted as well as the
    presence or absence of a partner or friend during the abortion.
    Results The age of the women varied from 14 years to 46 years and the length of
    gestation between 86 and 153 days. Indication for the abortion was socio-economic in
    66% of the women. Young women, women with no previous birth and women with higher
    gestation showed a significant higher pain-intensity (VAS) and the requirement of pain
    treatment was higher for these women during second trimester medical abortion. Pain-
    intensity VAS >7 (severe pain) was reported by 63% of the women at some time during
    the abortion. Intavenous morfine was given to 80% of the women. Paracervical blockade
    (PCB) was given to 21% of the women. There was no significant difference in pain-
    intensity, morphine- or PCB-requirements related to the presence of a partner, parent or
    friend during the abortion nor to the indication for the termination of the pregnancy
    (unwanted pregnancy or foetal malformation).Univariat analyses, Chi2-test (p=0.05) and
    Mann-Whitney´s test were used for the data analyses.
    Discussion Management of pain during second trimester abortion must be focused on the
    women’s need. Individual care is crucial for optimal pain treatment. To reduce the high
    frequency of severe pain one step is early active pain treatment to women with known
    predictors for higher pain experience. Different methods of pain treatment should also be

    available (i.ex. NSAID, PCB). Education of the staff in pain management and caring is
    needed to make the abortion care more focused on pain treatment and create a high
    quality and non-judgemental atmosphere. Further research is needed to improve the care
    of women undergoing second trimester abortion.
    Conclusions Young women, women with no previous birth and women with higher
    gestation showed a significant higher pain-intensity (VAS) and the requirement of pain
    treatment was higher for these women during second trimester medical abortion.

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    FC13

    Paracervical block (PCB) as pain treatment during second-trimester medical termination of pregnancy - a randomised controlled trial with bupivacaine versus sodium chloride.

    Inga-Maj Andersson, Lina Benson, Kyllike Christensson, Kristina Gemzell-Danielsson
    Södersjukhuset AB, Stockholm, Sweden

    The most common side effect of misoprostol is pain, however there are sparse studies of pain and pain treatment during MToP, especially in second-trimester abortion. Pain reported in second-trimester medical abortion is often intense, and peaks when the  expulsion occurs.
    Objectives: The aim of the present study was to determine if PCB administered before the onset of pain could decrease women´s pain experience during second-trimester MToP.
    Method: A double-blinded randomised controlled trial, with 113 participants included, was performed during May 2012 until April 2015.  Women who consented to participate were randomly allocated to receive a PCB with either 20 ml local anaesthesia (bupivacaine 2.5 mg/ml) or 20 ml sodium chloride 9mg/ml. The PCB was applied one hour after the first dose of misoprostol as a 2 to 4 millimetre deep paracervical injection into the mucosa at two sites (2 and 8 o´clock). The experience of pain was measured by visual analogue scale (VAS) at the time of administration of the first dose of misoprostol (baseline) and thereafter repeated every half hour during the abortion until the  expulsion. The main outcome was the highest pain intensity recorded on the VAS scale. Secondary outcomes were the induction-to-abortion interval measured from the start of misoprostol to  expulsion, the total morphine consumption, safety and side effects.
    Results: No statistically significant differences were observed between the two groups with regard to the highest and lowest pain intensity and morphine consumption. There was no difference in efficacy between the groups, neither in induction-to-abortion interval and time to placental expulsion nor in the rates of surgical intervention or the need for any additional treatment.
    Conclusion: It can be concluded that prophylactic PCB did not lead to a clinically significant reduction in maximal pain scores and the need for additional opiates during second-trimester MToP.