Management of Clients that Request a Termination of Pregnancy
These protocols are intended for the use of students, interns and registrars within Tygerberg hospital and its immediate catchment area only. Always consult with a senior colleague if you are unsure of the correct management.
Initial evaluation and administrative responsibilities
Assessment and management for women who qualify for TOP
An early, unwanted pregnancy infers:
- A breakdown in contraceptive usage or barriers to contraception services
- Exposure to sexually transmitted diseases
- Possible coercion, rape or incest
- Potential complications of early pregnancy (ectopic, molar, failed pregnancy etc.)
NB! All of which must be adequately dealt with before TOP counselling is considered.
This protocol must be read in conjunction with the following documents (available on request):
• Choice on Termination of Pregnancy Act (No 92 of 1996)
• Choice on Termination of Pregnancy Amendment Act (No 1 of 2008)
• Provincial Policy for Standardised Guidelines and Protocols on the Termination of Pregnancy Services (Circular H157/2010)
• WHO Guideline “Safe abortion: technical and policy guidance for health systems” [2012]
Additional advisable reading
• RCOG Evidence-based Clinical Guideline Nr 7 “The Care of Women Requesting Induced
Abortion” (2011).
• Conscientious objection and the implementation of the choice of termination of pregnancy act (Naylor & O’Sullivan; Women’s Legal Centre)
INITIAL EVALUATION AND ADMINISTRATIVE RESPONSIBILITIES
Administrative Responsibility of the Gynaecological Out Patient clinic:
- Ensure that:
- Clients that are booked for TOP evaluation will be fast-tracked to ensure early management. Their folders will be part of the stack of “B1”-new patients and must be evaluated in that order.
- TOP folders are part of general clinic and should not be sidetracked or placed to one side.
- TOP clients are not grouped together, asked to wait until the end of the clinic or otherwise demeaned, branded or stigmatised.
Responsibility of all the Doctors in the Gynaecological Out Patient clinic:
- Clients can be initially assessed by any doctor (including interns). To maintain confidentiality it is advisable that students do not take the initial history; they can do the gynaecology examination, wet mount and/or cervical cytology when indicated.
- A proper history and general gynaecological evaluation should be done.
- Basic ultrasound assessment to ascertain the pregnancy location and viability.
- Request appropriate special investigations (i.e. blood group, syphilis and HIV)
- Offer HIV counselling and testing if client does not know her status.
- Write clear notes and document what counselling and management has been done.
- Provide general counselling on sexual health and contraceptive
- If a woman then qualifies for a TOP then refer to Section 2.
- Provide information on all choices provided before going to section 2. (i.e. adoption)
- At this stage, conscientious objectors can refer the client to a colleague to continue with the directed TOP counselling and prescription of drugs. Refer to Section 3.
Responsibility of the nursing personnel for the clinic:
- Ensure that
- Pregnancy test is positive
- Haemoglobin, HIV and Syphillis serology is done
- Rh is done if > 12w0d
At all times ensure that TOP clients are allowed to exercise their rights in terms of the Choice on TOP Act.
ASSESSMENT AND MANAGEMENT FOR WOMEN WHO QUALIFY FOR TOP
- Inform the client about the TOP act and her rights according to the act.
- After the initial evaluation as set out in Section 1, Complete the “TYGERBERG TOP ASSESSMENT” form and the Annexure A of the “NOTIFICATION OF TERMINATION OF PREGNANCY IN TERMS OF SECTION 7 OF THE ACT” form.
- Ask if the client would like to see a social worker to help sort out social issues, relationship problems, discussion about adoption, help with return to school etc. Refer if needed.
NB! All clients’ ≤16 years must be referred to the social worker to sort out issues around statutory rape.
- Women will qualify for TOP if:
- If pregnancy gestation is ≤12 weeks 0 days TOP can be requested on demand
- If the pregnancy gestation assessed to be 12 weeks 1 day up to 20 weeks 0 days, TOP can only be done according to the indications stipulated in the act
- If a socioeconomic indication is obvious on initial assessment, the woman qualifies for TOP on social grounds between 12 weeks 1 day up to 20 weeks 0 days. The social worker’s role is to assess socioeconomic conditions and make a recommendation if uncertainty exists.
- Provide appropriate counselling on the methods of TOP
| Method | Advantages | Disadvantages |
| Medical |
- Used early during pregnancy - Resembles a natural miscarriage - Often considered more private - Usually avoids intervention and anaesthesia - High success rates |
- Often requires at least 2 visits - Takes days, sometimes weeks to complete - Efficacy decreases at later gestations - Women may see blood clots and products of conception |
| Surgical |
- High success rate (>99%) - May require only one clinic visit - Procedure completed within minutes |
- Involves invasive procedure - Often considered to be ‘less private’ - Facilities not always available. |
- Depending on the gestational age the preferred method for TOP in Tygerberg Hospital:
- <9w (63 days): Medical TOP as outpatient
- 9wk0d to 17w6d: Surgical TOP in the Gynaecological Day Theatre (GEK Theatre)
- 18w0d to 20w0d: Medical TOP in J4 ward under the care of the admitting gynaecological firm or Surgical TOP if GEK facilities can accommodate
- 9wk0d to 20w0d: Medical TOP in J4 ward under the care of the admitting firm. Done if the patient expresses preference for Medical TOP after counselling, or due to the lack of Gynaecological Day Theatre space and the TOP cannot be delayed to next available theatre space
CONSCIENTIOUS OBJECTION
- The right to freedom enshrined in the constitution of South Africa protects the moral autonomy of individuals, including the right not to perform a TOP based on conscience, religion, thought or belief.
- It also protects the moral autonomy of women to make decisions to have abortions, based on their beliefs.
- Any clinician in the department of O&G who objects to performing a TOP must register as a conscientious objector with your immediate supervisor (Dr S Gebhardt); this request will be placed on your personal folder and your choice respected.
- Objection is limited to the staff directly involved in the TOP procedure. Ancillary staff (e.g. ward clerks, catering etc.) and staff involved in the general care of a patient may not refuse to provide standard care to a TOP client.
- Clinicians who object may not refuse the basic care and assessment of any patient and should still ensure that the initial assessment in Sections 1 (as for all newly referred gynaecological patients) are done
- Once the initial evaluation is completed then the client can be appropriately referred to a colleague for further management as set out in Section 2.
- The conscientious objector offers to help this colleague with some of his/her work while they are managing the TOP clients as set out in Section 2.
- The right to conscientious objection EXCLUDES:
- The provision of adequate information about a TOP and a client’s rights in terms of the law
- The management of general gynaecological concerns related to the pregnancy itself
- The management of complications of TOP, where the life of the women is in danger
- The termination of pregnancy where continuation of the pregnancy poses a serious danger to the life or health of a woman, regardless of the gestational age.
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Tygerberg Hospital, Department of Obstetrics and Gynaecology; Protocol For Management Of Clients That Request a Termination Of Pregnancy; Version: May 2013; Last checked for updates by EMGuidance: Oct 2023