I want to offer medication abortion, but I’m worried about all the phone calls I might get after hours.

Medication abortion is a safe, effective, patient-centered method of providing first-trimester abortion; but, without clear directions, the process can be confusing for patients to navigate. Comprehensive counseling at the time of the initial visit can eliminate several patient concerns/questions, and as a result, eliminate extra burden on the provider receiving telephone calls. We recommend providing patients with both oral and written instructions that detail the process, normal side effects, and what symptoms warrant a phone call. (For examples of written patient instructions, see these aftercare instructions for medication abortion)

In your initial counseling session, walk the patient through the process step-by-step. First, discuss the time delay between mifepristone and misoprostol (6-72 hours with vaginal misoprostol, 24-48 hours with buccal misoprostol for up to 9 weeks, or 24-48 hours with sublingual misoprostol to 10 weeks), and note in written form when the patient plans to or has taken the mifepristone, and when she can take the misoprostol. Emphasize to the patient that she should eat and drink prior to using the misoprostol. At the time of this initial visit, the patient should be provided with pain medication (NSAIDs and oral narcotics) and encouraged to take the NSAIDs one hour prior to misoprostol administration, and the narcotics, if needed, after onset of cramps. Inform her that bleeding often starts an hour to a few hours after misoprostol administration, and can be heavier than a period and resemble a miscarriage. Remind her that it is not unusual for bleeding to start and stop over the next two weeks. Other symptoms a patient may experience with misoprostol include: nausea, vomiting, diarrhea, headache, and some dizziness. Finally, reassure her that some women will experience strong emotions and this is a normal part of the process.After reviewing all of the above, you can give the patient explicit instructions for problems that warrant a phone call, such as:

1. She is soaking through 2 pads an hour for 2 hours back to back
2. No bleeding has occurred 24 hours after administration of misoprostol
3. She starts to feel very ill after the heavy bleeding is over

Providing the patient with clear instructions relevant to her health literacy level in both written and oral form will decrease the rate of phone calls a provider receives for non-urgent concerns.

Resources

Aftercare instructions (vaginal administration of misoprostol)

Aftercare instructions (buccal administration of misoprostol)

Algorithm for phone Triage of bleeding with medication abortion

References

Medical management of first-trimester abortion. Practice Bulletin No. 143. American College of Obstetricians and Gynecologists. Obstet Gynecol 2014;123:676−692.

Creinin MD, Danielsson KG. Medical abortion in early pregnancy. In: Paul M, Lichtenberg ES, Borgatta L, Grimes DA, Stubblefield PG, & Creinin MD, editors. Management of unintended and abnormal pregnancy: comprehensive abortion care. Hoboken (NJ): Wiley-Blackwell; 2009. p. 111-34.

Bryant AG, Regan E, Stuart G. An Overview of Medical Abortion for Clinical Practice. Obstetrical and Gynecological Survey 2014; 69 (1): 39-45.

Bracken H, Dabash R, Tsertsvadze G, Posohova S, Shah M, Hajri S, Mundle S, Chelli H, Zeramdini D, Tsereteli T, Platais I, Winikoff B. A two-pill sublingual misoprostol outpatient regimen following mifepristone for medical abortion through 70 days’ LMP: a prospective comparative open-label trial. Contraception. 2014 Mar;89(3):181-6.

Pharma-free

Insights into abortion and miscarriage care is a publication of the Reproductive Health Access Project and Innovating Education in Reproductive Health, a project of the Bixby Center for Global Reproductive Health, UCSF. The Reproductive Health Access Project and Innovating Education in Reproductive Health do not accept funding from pharmaceutical companies. We do not promote specific brands of medication or products. The information in the Insights is unbiased, based on science alone.