1. 1 Basic Concepts for Delivering Postabortion Care Unsafe abortion worldwide The WHO estimates that: 20 million unsafe abortions occur worldwide each year. Each year more than 70,000 women die as a result of unsafe abortion. One out of every eight deaths related to pregnancy is due to unsafe abortion. (not indicated in text – NJ)

2. 2 Basic Concepts for Delivering Postabortion Care Factors that contribute to maternal mortality Poverty Poor nutrition Illiteracy Lack of access to health clinics Lack of sexual education Inferior quality of services (perceived or real) Women’s lack of control over their own sexual and reproductive lives Legal restrictions on abortion

3. 3 Basic Concepts for Delivering Postabortion Care The current state of PAC in many health clinics Medical equipment is obsolete or in poor condition Abortion patients are not treated with respect and sympathy Services are not well organized and supervision is poor Services are not accessible in rural and outlying areas Patient satisfaction is not the central focus Contraceptive counseling is not considered part of comprehensive patient care A limited variety of contraceptive methods is offered Patients’ medical, social and cultural circumstances are not taken into account

4. 4 Basic Concepts for Delivering Postabortion Care Lack of adequate staff Inadequate physical conditions Lack of necessary equipment and medicine Lack of training in PAC Problems communicating with patients Lack of political decision making Lack of support from leaders Lack of respect and understanding for patients Increased staff workload and burnout Potential difficulties in providing PAC services

5. 5 Basic Concepts for Delivering Postabortion Care Inadequate infection-prevention programs Inadequate referral systems Inadequate monitoring and follow-up of training processes Administrative separation of emergency and contraceptive services Resistance to using manual vacuum aspiration (MVA) Potential difficulties in providing PAC services (cont’d)

6. 6 Basic Concepts for Delivering Postabortion Care Elements and Purposes of PAC elements Ensure that women have access to the full range of reproductive health services they need to protect their health Links between emergency abortion treatment services and comprehensive reproductive health care Prevent repeat unwanted pregnancies and abortion Postabortion contraceptive counseling and services Reduce maternal mortality and morbidityEmergency treatment services for complications of spontaneous or unsafely induced abortion PURPOSEELEMENT

7. 7 Basic Concepts for Delivering Postabortion Care Health care providers should: Respect and support patients and their personal situations Exhibit nonjudgmental attitudes Respect patients’ confidentiality Respect each patient’s right to obtain information and make health care decisions Never coerce patients Provide opportunities for patients to express feelings and ask questions Show sensitivity to patients’ concerns

8. 8 Basic Concepts for Delivering Postabortion Care Empathetic people are: Genuine, pleasant and friendly Honest Quick to establish relationships with others Compassionate Helpful Good listeners Gentle and affectionate Nonjudgmental

9. 9 Basic Concepts for Delivering Postabortion Care Counseling before the MVA procedure can be affected by: Short amount of time to establish trust between patient and provider Lack of privacy and comfort Patient’s physical pain Patient’s feeling afraid, angry, relieved or anxious Patient’s inability to concentrate on detailed information Patient’s unwillingness to talk with a counselor about contraception Patient’s suspicion or fear regarding the purpose of the counseling

10. 10 Basic Concepts for Delivering Postabortion Care Techniques for effective communication Use short sentences and language the patient understands Repeat important points Encourage patient’s questions and give clear answers Listen to and acknowledge the patient’s feelings and concerns Use appropriate nonverbal language, such as tone of voice, gestures, eye contact and posture

11. 11 Basic Concepts for Delivering Postabortion Care Nonverbal communication techniques: Be comfortable and poised Face the patient Make eye contact Use friendly gestures – for instance, nod your head and lean forward Use a tone of voice that conveys interest and understanding Notice patient’s nonverbal communication Avoid appearing distracted – for example, do not fidget or look at the clock Avoid appearing tired, annoyed or bored – do not frown, shake your head or yawn Avoid appearing judgmental – do not point or look accusingly

12. 12 Basic Concepts for Delivering Postabortion Care Active listening Active listening requires more than simply hearing what a patient says. Active listening is listening in a way that communicates empathy, understanding and interest. 1.How do you know if a person is really listening? 2.How do you know when someone is not listening?

13. 13 Basic Concepts for Delivering Postabortion Care Patients’ rights All patients have the right to: Information Accessible services Safe services Choices Privacy Confidentiality Dignity Comfort Opinions Follow-up care

14. 14 Basic Concepts for Delivering Postabortion Care Principles for interacting with abortion patients Respect patients’ privacy Respect patients’ rights Demonstrate concern and willingness to help Listen actively Respond to patients’ fears, problems and concerns Treat promptly Manage pain with support and medication Provide comprehensive information

15. 15 Basic Concepts for Delivering Postabortion Care Purpose of patient assessment Identify any pre-existing conditions that may affect treatment. Confirm that abortion has occurred. Determine cause of abortion. Determine duration of symptoms. Determine patient’s emotional state. Determine patient’s physical condition. Determine uterine size and position. Classify abortion. Identify any presenting complications. Make an accurate diagnosis. Develop a treatment plan.

16. 16 Basic Concepts for Delivering Postabortion Care Emergency treatment of postabortion complications includes: Performing an initial evaluation to confirm the existence of complications due to abortion. Talking to the patient about her clinical condition and the treatment plan. Performing a medical evaluation (accurate history, physical and pelvic exams focused on the problem). Referring and transferring the patient quickly if she needs treatment beyond the capacity of the clinic. Stabilizing emergency conditions and treating any complications. Vacuuming remaining tissue to evacuate the uterus.

17. 17 Basic Concepts for Delivering Postabortion Care Bimanual Exam

18. 18 Basic Concepts for Delivering Postabortion Care Before starting the procedure Ask the patient to urinate. Place her in gynecological position with her buttocks approximately 2 inches (5 centimeters) over the edge of the treatment table. Cover her legs, abdomen and buttocks with clean or sterile cloths. In most cases, shaving the genital area is not necessary. In most cases, cleaning or wetting the vulva is not necessary.

19. 19 Basic Concepts for Delivering Postabortion Care Preparing the patient for MVA Evaluate her emotional state. Answer all her questions, be empathetic and do not judge her. Explain the procedure, its advantages and risks (use simple language). Attempt to calm and relax her. Demonstrate relaxation breathing exercises. Ask about her needs for contraception. Earn her trust (be attentive, patient, gentle and sensitive).

20. 20 Basic Concepts for Delivering Postabortion Care Pain Pain is the sensory and emotional experience associated with actual or potential tissue damage. Pain includes not only the perception of an uncomfortable stimulus but also the response to that perception.

21. 21 Basic Concepts for Delivering Postabortion Care Pain depends on: The intensity of stimulus on nerve endings (frequency and breadth) Individual predisposition for perceiving stimuli (anxiety and previous tension) Fear from previous experiences, expectations or misunderstandings Emotions

22. 22 Basic Concepts for Delivering Postabortion Care Ways that pain is amplified StimulusTension Pain Response Fear CNS

23. 23 Basic Concepts for Delivering Postabortion Care Goal of pain management –To minimize the woman’s anxiety and discomfort with the least amount of risk to her health LEAST PAIN LEAST RISK

24. 24 Basic Concepts for Delivering Postabortion Care Types and origins of pain Cervical dilation and/or stimulation Deep intense pain Diffuse lower abdominal pain with cramping Scraping of uterine wall, movement of uterus or muscle spasms

25. 25 Basic Concepts for Delivering Postabortion Care Uterus Vagina Cervix T12 L1 L2 L3 L4 S2 S3 S4 terova g ial plexus: cervix, uppervagin Nerves that transmit pain Uterovaginal plexus -- cervix, upper vagina Hypogastric plexus -- body, fundus of uterus

26. 26 Basic Concepts for Delivering Postabortion Care Requirements for effective pain management Personal interaction between patient and health care providers Quiet, private treatment room Friendly, calm, attentive health workers Clear explanation of what is happening Efficient, well-trained team Counseling and reassurance provided during the procedure

27. 27 Basic Concepts for Delivering Postabortion Care Purposes of supportive interaction Ease fears: Instill confidence in the health care team, provide counseling, clarify concepts Reduce tension: Humane treatment, understanding, empathy, deep-breathing exercises, distraction Control pain: Intensity, frequency, duration

28. 28 Basic Concepts for Delivering Postabortion Care Types of pain medication Analgesia - eases sensation of pain Anxiolytic - depresses central nervous system functions (reduces anxiety, relaxes muscles) Anesthesia - deadens all physical sensation

29. 29 Basic Concepts for Delivering Postabortion Care Preferred characteristics of anesthetics for use with MVA Rapid-acting Easy-to-use Low-risk Induces amnesia Quick recovery Low-cost

30. 30 Basic Concepts for Delivering Postabortion Care Types of anesthesia General -affects pain receptors in brain, produces complete unconsciousness Regional -blocks sensation from a specific point on the spine, patient awake Local -interrupts transmission of sensations in local tissue only

31. 31 Basic Concepts for Delivering Postabortion Care Effective pain management for MVA Gentle handling of the patient The proper combination of drug types (anesthetics and analgesics)

32. 32 Basic Concepts for Delivering Postabortion Care Paracervical block Use a 22-gauge spinal needle or needle extender with a 10cc syringe. Aspirate before each injection.

33. 33 Basic Concepts for Delivering Postabortion Care Paracervical block (cont’d) About 2 ml lidocaine into each injection site Inject at 3, 5, 7, 9 o’clocks (maximum dose = 10-20 ml, based on patient’s body weight) Wait 2-4 minutes for effect

34. 34 Basic Concepts for Delivering Postabortion Care Lidocaine for paracervical block Duration: 60-90 minutes Advantages: very few allergic reactions Toxic reactions to lidocaine: Mild: numbness in the mouth or on the tongue, dizziness and light- headedness and/or buzzing in the ears Severe: sleepiness and disorientation, muscle twitching, shivering, slurred speech, tonic-clonic convulsions and/or respiratory depression-arrest Latency period: short Maximum concentration: 5 to 20 minutes after administration Degradation: hepatic metabolism

35. 35 Basic Concepts for Delivering Postabortion Care Complications of local anesthetics Allergic reaction (rare): If hives or rash: give diphenhydramine (Benadryl) 25-50 mg IV If respiratory distress: give epinephrine 0.4 mg subcutaneously, and support respiration Toxic reaction (rare): If mild: give verbal support, monitor closely for a few minutes If severe: give immediate oxygen and slow IV diazepam 5 mg

36. 36 Basic Concepts for Delivering Postabortion Care Instruments for MVA Cannulae Denniston Dilators Ipas MVA Syringe Note: The MVA syringe is also known as an aspirator. Some vacuum aspiration devices look different than the one pictured. 36

37. 37 Basic Concepts for Delivering Postabortion Care Use MVA in postabortion care for: Threatened or imminent abortion Inevitable abortion Incomplete abortion Infected abortion Missed abortion Anembryonic pregnancy Hydatidiform mole Retained placental products 37

38. 38 Basic Concepts for Delivering Postabortion Care Two types of vacuum aspiration Electric Manual Electric pump Manual syringe Constant suction Suction not constant 350 – 1,200 cc of storage capacity 60 cc of storage capacity Cannulae Rigid or flexible Flexible Diameter of 4 to 16 mm Diameter of 4 to 12 mm 38

39. 39 Basic Concepts for Delivering Postabortion Care Adapted from Greenslade et al. 1993 Efficacy of MVA Treatment of Incomplete Abortion Studies19 Procedures>5,000 Aspiration timeGenerally from 3 to 5 minutes Efficacy rate>98% 39

40. 40 Basic Concepts for Delivering Postabortion Care Safety Adapted from Grimes et al. 1977 Rate of complications in vacuum aspiration (electric and manual) vs. D&C in abortion reported in JPSA study Type of procedure Total complicationsSerious complications Vacuum Aspiration5.00.4 D&C10.60.9 40 Percentage of women sustaining complications

41. 41 Basic Concepts for Delivering Postabortion Care Adapted from Baird et al. 1995. 41 Average Number of Complications per 100 Procedures in Six Studies Comparing Vacuum Aspiration and Sharp Curettage Type of ProcedureAverages Across Six Studies Excess Blood Uterine Loss Perforation Averages Across Three Studies Pelvic Infection Cervical Injury Vacuum Aspiration Sharp Curettage 5.3 0.13 10.8 0.3 3.8 1.1 4.5 2.9

42. 42 Basic Concepts for Delivering Postabortion Care Advantages of MVA in treatment of incomplete abortion Requires only slight dilation and scrapes gently Lower risk of complications Lower cost of services Lower resource use Decreased need for hospitalization Outpatient procedure Local anesthesia Patients recover and return home more quickly 42

43. 43 Basic Concepts for Delivering Postabortion Care Decrease in costs in KenyaDecrease in length of hospital stay in Mexico Resource savings associated with MVA Hospital 1 Hospital 2 Average cost per patient in $US Average time in hours Hospital 1Hospital 2 43 Adapted from Johnson et al. 1993

44. 44 Basic Concepts for Delivering Postabortion Care Comparison: Treatment of incomplete abortion Frequently more than 24 hours Usually less than 6 hoursHospital Stay Often operating roomUsually treatment roomService Delivery Site Often general anesthesiaUsually local anesthesiaPain Management Usually requiredOccasionally requiredCervical Dilation Higher ratesLower ratesComplications Efficient*Very efficientEfficiency D&CMVA 44 *Efficiency is defined as a successful uterine evacuation with no remaining tissue

45. 45 Basic Concepts for Delivering Postabortion Care Preliminary steps Take a clinical history Perform physical and pelvic exams Notice how she feels Ask the patient to urinate Place the patient in the gynecological position and cover her with a clean cloth Follow infection prevention protocols Evaluate and treat any complications Talk to the patient about contraception Determine appropriate type of pain management in order to decrease discomfort and pain Explain procedure to patient 45

46. 46 Basic Concepts for Delivering Postabortion Care Possible presenting complications Rapid pulse Falling blood pressure Excessive bleeding Repeat abortions Cervical/uterine perforation Vagal reaction Hemorrhage Hypotension Incomplete evacuation Pelvic infection Acute hematometra Air embolism 46

47. 47 Basic Concepts for Delivering Postabortion Care Precautions Determine uterine size and position –Because of the possibility of fibroids or other anomalies, do not perform MVA until uterine size and position are determined. Use appropriate cannula size –Cannula of incorrect size may result in damage to cervix, loss of suction or retained tissue. Insert cannula carefully –Do not insert cannula forcefully as forceful movements may damage the cervix or uterus. 47

48. 48 Basic Concepts for Delivering Postabortion Care Instruments and materials needed for MVA Vaginal speculum Tenaculum Forceps Uterine or gynecological tweezers Basins for antiseptic and tissue Needle extenders Denniston or Pratt Dilators, of 3 to 14 mm in diameter 10cc syringe with spinal needle #22 of 3.5 inches or needle #23 Local anesthesia (1% or 2% lidocaine without epinephrine) Antiseptic solution Small gauze (20) Sterile gloves Sterile fields 48

49. 49 Basic Concepts for Delivering Postabortion Care Selecting the cannula Adapters for the double-valve syringe are color-coded to the dots on the corresponding cannula. Approximate uterine size (weeks LMP) Approximate size of the cannula 5 to 7 LMP4 to 6 mm 8 to 9 LMP7 to 8 mm 10 to 12 LMP9 to 12 mm 49

50. 50 Basic Concepts for Delivering Postabortion Care Selecting adapters CannulaeSyringe 4,5, and 6 mmSingle 4, 5, and 6 mmDouble 7 mmDouble 8 mmDouble 9 mmDouble 10 mmDouble 12 mmDouble Select the adapters based on the cannula and the type of syringe to be used 50 Adapter Not needed Blue Brown Beige Dark brown Dark green Not needed

51. 51 Basic Concepts for Delivering Postabortion Care Inspect the syringe Connect the adapter Inspect the plunger and the buttons of the valve Close the safety valve Preparing MVA instruments 51

52. 52 Basic Concepts for Delivering Postabortion Care Prepare the vacuum in the syringe Make sure the syringe holds a vacuum Check that the instruments, the materials and medications are in the tray Preparing MVA instruments (continued) 52

53. 53 Basic Concepts for Delivering Postabortion Care Preparing the cervix Place the speculum Wipe the cervix and the vagina with an antiseptic Stabilize the cervix with the tenaculum Apply paracervical block, if required 53

54. 54 Basic Concepts for Delivering Postabortion Care Options for stabilizing the cervix 1.Place the two arms of the tenaculum in the anterior position 2.Place the two arms of the tenaculum in the posterior position 3.Place one arm of the tenaculum inside the cervical canal and the other at the 10 o’clock position 54

55. 55 Basic Concepts for Delivering Postabortion Care Cervical dilation Grasp the narrowest dilator in the middle Hold it between the thumb and index finger with your hand below the dilator Insert it gently until it passes through the internal os 55

56. 56 Basic Concepts for Delivering Postabortion Care Cervical dilation (continued) Grasp the dilator in the middle Hold it between the thumb and index finger with your hand above the dilator Withdraw the dilator Rotate it carefully and insert it again Dilate the cervix up to the size of the Denniston dilator that is required for the selected cannula 56

57. 57 Basic Concepts for Delivering Postabortion Care Inserting the cannula Apply traction to the tenaculum gently Insert the selected cannula gently through the cervix with a rotation movement Do not touch the end that will be inserted into the uterus 57

58. 58 Basic Concepts for Delivering Postabortion Care Uterine sounding 6cm There are 6 cm from the tip of the cannula to the first dot, and 1 cm between each dot. Push the cannula slowly inside the uterine cavity until it touches the fundus 58

59. 59 Basic Concepts for Delivering Postabortion Care Connecting the cannula to the syringe Hold the cannula with the thumb and index finger, while holding the syringe with the other hand Connect the cannula to the syringe Do not push the cannula forward in the uterus 59

60. 60 Basic Concepts for Delivering Postabortion Care Creating a vacuum When the safety valve is released, the vacuum is transferred to the uterus through the cannula The passage of blood and tissue through the cannula to the syringe begins 60

61. 61 Basic Concepts for Delivering Postabortion Care Evacuating uterine contents Hold the cannula with the thumb and index finger and the syringe with the ring and little fingers Move the cannula back and forth gently and slowly, rotating the cannula and the syringe at the same time Do not withdraw the aperture of the cannula beyond the external cervical os Do not grasp the syringe by the plunger arms! 61

62. 62 Basic Concepts for Delivering Postabortion Care Loss of vacuum during the procedure The MVA Syringe may lose suction if: Syringe is full Cannula has come out of the external os Cannula is not properly attached Cannula is too small Black O-ring is not properly placed in the plunger Uterine perforation has occurred 62

63. 63 Basic Concepts for Delivering Postabortion Care If the syringe becomes full: 1.Close the valve 2.Disconnect the syringe, leaving the tip of the cannula inside the uterus - Do not push the plunger in when disconnecting the syringe! 3.Open the valve 4.Empty the contents of the syringe in a container 5.Re-establish the vacuum, reconnect the syringe, and continue, or connect another prepared syringe and resume the aspiration 63

64. 64 Basic Concepts for Delivering Postabortion Care Reinsert the cannula Detach the syringe and empty its contents Re-establish the vacuum Reconnect the syringe Resume the procedure Do not allow the cannula to come in contact with anything that may not be sterile. If the cannula has been withdrawn from the external os: If contamination occurs, use another cannula! 64

65. 65 Basic Concepts for Delivering Postabortion Care If tissue clogs the cannula’s aperture: Withdraw the cannula slowly up to the external os. The release of air will cause the tissue to pass through to the syringe. Reinsert the cannula in the uterus, detach the syringe, empty its contents, re-establish the vacuum and resume the procedure. Never try to unclog the cannula by pushing back into the barrel. 65

66. 66 Basic Concepts for Delivering Postabortion Care Signs of completion of the procedure There is pinkish foam in the cannula No more tissue is seen passing through the cannula A gritty sensation is felt The uterus grips the cannula and it is difficult to move it 66

67. 67 Basic Concepts for Delivering Postabortion Care Recognizing and managing uterine perforation Signs: Instruments inserted beyond the fundus Excessive bleeding Fat or organ fragments in the aspirated tissue 67 Treatment: Usually seals itself off as uterus contracts May require laparotomy or laparoscopy Begin IV fluids and/or antibiotics Give blood transfusion, if necessary Repair the damage by suturing Give oxytocics after the surgery Monitor vital signs Give ergotamine Observe patient until her vital signs are normal

68. 68 Basic Concepts for Delivering Postabortion Care After the procedure Disconnect syringe Withdraw cannula and tenaculum Check for active bleeding in the uterus or in the cervix Withdraw speculum if bleeding has stopped Place all instruments in 0.5% chlorine solution Perform bimanual exam 68

69. 69 Basic Concepts for Delivering Postabortion Care Inspecting the tissue 69 Follow protocols for infection- prevention Strain and rinse the tissue Using a transparent container, inspect the material by examining it with a light from behind Make sure all the tissue has been withdrawn Send the tissue to the pathology lab as indicated

70. 70 Basic Concepts for Delivering Postabortion Care Inspecting the tissue (cont’d) Inspect the tissue, looking for: villi, tissue, membranes or fetal parts (after 9 weeks LMP) 70

71. 71 Basic Concepts for Delivering Postabortion Care Patient recovery and discharge In recovery: Take patient’s vital signs Allow the patient to rest comfortably where staff can monitor her recovery Check that bleeding and cramping have lessened 71 Discharge when: Her vital signs are normal She can walk without assistance She has received information about follow-up care and recovery She has been counseled and informed about her return to fertility and contraception

72. 72 Basic Concepts for Delivering Postabortion Care Patient recovery Performing the MVA procedure with a low level of medications for pain management leads to a quick recovery of the patient. 72

73. 73 Basic Concepts for Delivering Postabortion Care What the patient needs to know 73 She should expect some uterine cramping and bleeding. Her normal menstrual period should begin within 4-8 weeks. She should take medications as prescribed. She should not have sex or put anything into the vagina until a few days after bleeding stops. She could become pregnant before her next period is expected. Contraception can prevent or delay pregnancy, if she so desires. She should schedule a follow-up visit. Where to seek medical attention if she experiences prolonged cramping, excessive bleeding, severe pain, fever, chills, malaise or fainting.

74. 74 Basic Concepts for Delivering Postabortion Care Postabortion contraception: breaking the cycle of repeat unwanted pregnancy and unsafe abortion Unwanted or high- risk pregnancy Restricted access to safe abortion services Unsafe abortion Emergency abortion care Postabortion Contraception Contraceptive non-use, non-availability or failure; involuntary or unplanned sex

75. 75 Basic Concepts for Delivering Postabortion Care Return to fertility First-trimester abortion: A woman usually recovers her fertility during the first two weeks after the abortion. Second-trimester abortion: A woman usually recovers her fertility during the first four weeks after the abortion.

76. 76 Basic Concepts for Delivering Postabortion Care All modern methods can be considered for use after an abortion, barring contraindications. If a woman does not want to become pregnant again, she needs a method that will be efficient and easy to use. Begin the use of hormonal methods during the first week after treatment for an incomplete abortion. Postpone the use of natural contraception until a full, normal cycle has resumed. General recommendations

77. 77 Basic Concepts for Delivering Postabortion Care The woman’s reproductive plans Tension and pain The woman’s previous experience with contraception The woman’s level of knowledge about contraception and reproduction in general Potential risk of contracting STDs or AIDS Factors that can affect contraception selection

78. 78 Basic Concepts for Delivering Postabortion Care Continuous access to services and supplies Access to a qualified provider, in case of complications or if she wants to change methods Access to resources To use a contraceptive method efficiently, women need: What factors affect access to resources?

79. 79 Basic Concepts for Delivering Postabortion Care Protocols for dispensing contraceptive methods and making referrals Are there national, regional or local regulations for different levels of care? Are they followed? Are they adequate for local circumstances and needs? Is there an efficient referral system? Are referral cards or notes provided at all levels of care?

80. 80 Basic Concepts for Delivering Postabortion Care Infection or sepsis Trauma to the genital tract and internal organs (perforation of the uterus, vaginal lesions, cervical leisonss) Hemorrhage and severe anemia Possible complications of incomplete abortion

81. 81 Basic Concepts for Delivering Postabortion Care Postpone surgical sterilization and IUD insertion until the infection is completely resolved or has been ruled out. All other methods may be considered. Contraception in case of suspected or confirmed infection

82. 82 Basic Concepts for Delivering Postabortion Care Postpone surgical sterilization and IUD insertion until the trauma has healed. The site and severity of the lesions can affect the use of a diaphragm or spermicides. Contraception when trauma has occurred to the genital tract

83. 83 Basic Concepts for Delivering Postabortion Care Hemorrhage may result in temporary anemia which resolves quickly. Female surgical sterilization should be postponed because of the risk of excessive blood loss and increased risks associated with anesthesia. Contraception after hemorrhage

84. 84 Basic Concepts for Delivering Postabortion Care The fallopian tubes may be difficult to locate, hindering surgical sterilization. IUD rejection is more likely. Wait six weeks after a second-trimester abortion to measure for placement and use of a diaphragm. Contraception after second-trimester abortion