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MTOP [Medical termination of pregnancy] - Coggle Diagram
MTOP [Medical termination of pregnancy]
Patient details
26 year old Maori presenting to PACU2 for an MTOP.
Patient is 14 weeks gestation; reason for MTOP is that there were abnormalities found at the 12 week scan (baby unlikely to make it to birth). This is the patient’s third pregnancy. Patient has support of her family and her husband is present- they also have social worker input throughout this process. She has not had an MTOP before, previous pregnancies were normal, uneventful births, healthy babies. The patient would like to keep the foetus and asked for us to refer to it as her “angel baby.”
Aim of an MTOP
Safe delivery/ termination
Supportive environment
Non-judgemental
Details of the scenario
Patient came in with cramping from the mifepristone that she had taken the previous day. Misoprostol was given as per protocol, and by the second dose she had delivered. Upon checking the contents it was noted that not all of the placenta had been delivered. The patient then begun to bleed heavily and this did not stop. Blood pressure began to drop and heart rate increase. Medications were given as per the haemorrhage pathway (see rest of concept map). Patient was then prepared for theatre where she had an ERPOC [evacuation of retained products of conception] and was admitted to hospital overnight for monitoring.
Abortion Legislation Act 2020
Decriminalised abortions; removing associated offences from the Crimes Act 196.
Health professionals no longer have to apply to the Abortion Advisory Committee.
Makes it easier for women to access abortion services in New Zealand.
Misoprostol
Prostaglandin E1 analogue
400mcg PV 3 hourly for 3 doses or until delivery.
92-98% complete termination when given with mifepristone
Contraindications- pregnancy (hence used for TOPs)
Adverse effects- GI upset, headache, nausea, uterine cramping and bleeding.
Section 25 needs to be completed before medication administration - needs to be checked by 2 nurses prior to administration
Mifepristone
Antiprogestogen
200mg PO 12-48 hours prior to first misoprostol dose.
Mifepristone leads to a 64-85% chance of complete termination when given alone.
Contraindicated in pregnancy (hence the use in TOPs)
Precautions- Patients with c section scars, IUDs.
Adverse effects- GI upset, heavy bleeding, hypotension.
Section 25 needs to be completed before medication administration- a doctor gives this the day prior
A Section 25 of the Medicines Act 1981 allows an authorised prescriber to use any medicine for treatment of one particular patient. The prescriber must provide patient details in the application as well as the reason the medications are to be use to have a section 25 approved. They must weigh up professional and ethical responsibilities when completing a section 25.
Entonox
Medicinal gas made up of oxygen and nitrous oxide.
Indications- Acute trauma, used for when only short term pain relief is required.
Contraindications- Conditions where gas is entrapped in the body ie. embolism.
Precautions- There is an increased sedative effect in patients that are taking morphine drugs and benzodiazepines.
Oxytocin
Pituitary hormone and uterine stimulant.
Also used to prevent and treat postpartum haemorrhage and uterine agony associated with TOPs.
Initially, 10 units are given IM
Once IV access has been established, then 40 units are given in 1000mL 0.9% NaCl over 4 hours.
Adverse effects- headache, tachycardia, nausea
Tranexamic acid
Antifibrinolytic, used for treatment of haemorrhage.
1000mg in 100mL 0.9% NaCl at 600mL/hr (takes 10 minutes) via guardrails.
Contraindications- DVT, PE, subarachnoid haemorrhage.
Adverse effects- GI upset
Other actions/ care to be done
Monitor and measure blood loss (patient lost nearly 1 litter of blood before theatre).
Comfort the patient and her husband.
Blood taken for FBC, crossmatch, and group & hold.
Alert gynae team of the patients status- keep regular updates
Prepare for theatre- book a bed for post procedure.
Find kete for baby as patient and husband want to bury baby in family plot.
Medication legislation
Medicines Act 1981- medicines can only be given by those authorised to administer medication under the authorisation of a prescriber OR in accordance with a standing order.
Before medication administration, nurses must ensure that all prescriptions are legible, are signed by the prescriber and is dated. The 7 medication rights need to be performed.
All medications involved with a patient having a termination need to be checked by two nurses when administering, and no standing orders are to be performed (however, according to TDHB policy telephone orders can be performed in the event of an emergency)
NZNO competencies and code of conduct: Nurses must ensure that they are practicing in accordance to their scope of practice, are familiar with the area’s policy around termination of pregnancy, at any time nurses can decline to partake in a termination of pregnancy. According to TDHB policy, nurses must have done a education day on terminations, as well as being signed off by an RN with experience.