14.4 Abortion Care: Options Counseling, Medication Abortion & Follow-Up

Options Counseling

The blueprint asks the midwife to provide options counseling for pregnancy, including continuation and termination, to refer for services to electively terminate pregnancy, to prescribe medication to electively terminate pregnancy, and to assess need for and facilitate socioemotional follow-up after termination. Scope of practice varies, but the counseling competency does not.

Non-directive counseling means presenting parenting, adoption, and abortion neutrally, in the patient's preferred language, without inserting the clinician's own values. Practical steps:

1. Confirm the pregnancy and establish gestational age by last menstrual period plus ultrasound when dating is uncertain — options and timing depend on it.
2. Ask an open question — "How are you feeling about being pregnant?" — before offering any information.
3. Screen for coercion, from a partner, family, or anyone else, and for intimate partner violence.
4. Give accurate, balanced information about each option, including adoption types (open, semi-open, closed) and who provides each service.
5. Document the discussion and the patient's decision, and make the referral concrete — a name, number, and appointment, not a pamphlet.

[!IMPORTANT] Know your state. Since Dobbs v. Jackson Women's Health Organization (2022), abortion legality, gestational limits, mandatory waiting periods, and even what a clinician may lawfully say or refer for vary enormously by state. The midwife is responsible for knowing the current law where they are licensed, and for knowing which nearby jurisdictions and telehealth services are available to patients when local care is unavailable.

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Medication Abortion

Regimen (combined, preferred):

• Mifepristone 200 mg orally — a progesterone-receptor antagonist that detaches the decidua and sensitizes the myometrium — followed 24 to 48 hours later by
• Misoprostol 800 mcg buccally (vaginal and sublingual routes are also used), a prostaglandin E1 analogue producing cervical softening and uterine contractions.

Efficacy and limits: approximately 95–98% complete through 70 days (10 weeks) of gestation, the FDA-labeled limit; ACOG supports evidence-based use through 11 weeks. A repeat misoprostol dose may be given if the pregnancy has not passed.

Misoprostol-alone regimens (800 mcg sublingually or vaginally every 3 hours for up to three doses) are used where mifepristone is unavailable and are less effective, roughly 78–93%.

What to tell the patient to expect: cramping and bleeding beginning 1 to 4 hours after misoprostol, heavier than a period, with clots, tapering over 1 to 2 weeks. Ibuprofen is more effective than acetaminophen and does not reduce efficacy.

When to call urgently: soaking two maxi pads per hour for two consecutive hours, fever above 38 °C persisting beyond 24 hours after misoprostol, severe pain unrelieved by analgesia, or foul-smelling discharge.

Contraindications: confirmed or suspected ectopic pregnancy, an IUD in place (remove first), chronic adrenal failure, long-term corticosteroid therapy, inherited porphyria, coagulopathy or current anticoagulation, and mifepristone or misoprostol allergy.

[!NOTE] RhD immune globulin update. ACOG's 2024 Clinical Practice Update and an SMFM statement now suggest forgoing routine Rh testing and RhD immune globulin for abortion or pregnancy loss at less than 12 0/7 weeks, because the likelihood of alloimmunization at that gestational age is very low. This reverses the long-standing practice of giving a 50 mcg mini-dose. Follow current institutional and state protocol, and be ready to explain the change.

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Procedural Abortion

• Uterine aspiration (manual or electric vacuum aspiration) is used in the first trimester and into the early second trimester, typically under paracervical block with or without sedation. It is a brief procedure with a very high completion rate.
• Dilation and evacuation (D&E) is the second-trimester method, usually preceded by osmotic dilators (laminaria or Dilapan-S) or pharmacologic preparation.
• Overall safety: the major complication rate for abortion is well under 1%, and the mortality rate is substantially lower than that of childbirth. This is a fact patients frequently have wrong and are entitled to hear accurately.

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Follow-Up and Confirming Completion

Routine in-person follow-up is not required after uncomplicated medication abortion. Completion is confirmed by any of:

• Serum hCG decline of at least 80% at 7 days after mifepristone;
• Ultrasound showing an empty uterus (note that a thick endometrial stripe alone is not an indication for intervention);
• A high-sensitivity urine pregnancy test at 4 weeks, or a low-sensitivity ("multi-level") test earlier;
• Patient-reported symptom checklists, which perform well in studies.

Contraception starts immediately. All methods can be initiated the same day, including an IUD placed at the time of aspiration or once completion of a medication abortion is confirmed. Ovulation can resume within 2 to 3 weeks.

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Socioemotional Follow-Up

• The most common emotional response is relief. The strongest predictor of psychological distress after abortion is a pre-existing mental health condition, not the abortion itself.
• The Turnaway Study followed people who obtained abortions and those turned away for being past a facility's gestational limit: those denied a wanted abortion had worse mental health in the short term and worse financial, physical health, and family outcomes years later.
• "Post-abortion syndrome" is not a recognized psychiatric diagnosis and should not be presented as one.
• Some patients do grieve, especially after a wanted pregnancy ended for fetal or maternal indication. Ask rather than assume: "How are you feeling about the decision now?"
• Screen for depression and anxiety, offer peer and professional support (All-Options talkline, Exhale, perinatal mental health providers), and revisit at the contraception or well-woman visit.
• Do not disclose the abortion in records or conversations beyond what care requires, and be aware of the legal-privacy environment in your state.