God can guide you through the most challenging decisions

5 MINUTE READ

From Luke’s Journal 2022 | Termination of Pregnancy | Vol.27 No.3

A Common Presentation

Julie is a 23-year-old woman who comes to see you in your General Practice. You have never met her before. Once the door is shut she bursts into tears. She then tells you over the course of the next five minutes that she is pregnant to a non-committed boyfriend. They have only been together for a month. She was taking the combined oral contraceptive pill at the time, so she is also surprised that this has happened. She has discussed it with her boyfriend and she wants to have an abortion. 

As a Christian doctor in the emergency room or general practice, being faced with a scenario like this can be very confronting. In front of you there is a young woman, obviously very distressed and for good reason. She probably has minimal, if any, financial resources and may often have little emotional and/or social support.

“As the doctor in this scenario, you may think you have very little to offer. It might conflict with your conscience in that you might not think abortion is the right choice, or you might feel guilty about denying this woman her request”.

This young woman is then faced with the daunting emotional, physical, and economic burden of raising a child alone. As the doctor in this scenario, you may think you have very little to offer. It might conflict with your conscience in that you might not think abortion is the right choice, or you might feel guilty about denying this woman her request. This leaves you feeling unsure of what to do. As a Christian, this is probably one of the most common and confronting scenarios that exist within medicine.  For a General Practitioner (GP), the above scenario is a common presentation. One quarter to one third of all Australian women have had an unplanned pregnancy.^1,2 Coombe et. al. reports that 73.4% of these women were using some form of contraception at the time of falling pregnant.¹ Taft et. al reports that 17% of unplanned pregnancies were unwanted and, of the unwanted pregnancies, 53.6% women gave birth, 30.4% women had abortions, and 15.2% women had miscarriages.²

A Practical Approach – Common Practice

Today, I would like to share with you a practical approach to supporting the patient in this scenario. My proposed approach considers Christian ethics in making decisions, and also utilises non-directive counselling as recommended by the RACGP, ACRRM, RANZCOG, and the Department of Health (National).^3,4,5 For those unfamiliar with non-directive counselling, it is a style of conversation that assumes people can solve their own problems without being provided with a direct solution from the counsellor.³ Rather, the counsellor provides unbiased, evidence-based information about all options and services available to the person.^3,5 For this to be therapeutic, the conversation requires a few things, including: a safe space (including time) for the patient to consider their options; discussion that takes into account the patient’s values; and finally, a consideration of the practicalities of the pregnancy and its impacts.^3,5

The first step in any consultation is history-taking.
In this, the information we require is as follows:

• Is this pregnancy planned or unplanned, wanted or unwanted?
• Last menstrual period, normal cycle length, and regularity.
• Investigation into possible pregnancy-related symptoms – nausea and vomiting, bleeding, cramping.
• Gynaecological history – sexual history, previous sexually-transmitted infections (STIs)/ pelvic inflammatory disease (PID), contraception, cervical screening history, gynaecological conditions or procedures
• Obstetric history including previous miscarriages, ectopic pregnancies terminations, pregnancy complications and outcomes
• Other medical history, medications including multivitamins, allergies, smoking, alcohol and recreational drug use
• Social history – occupation, living situation, social supports – family, friends, groups, spiritual history

Secondly, as per any consultation, we examine the patient and perform bedside investigations including:

• Blood pressure (<140/90), weight, urinalysis
• Cardiovascular, respiratory, abdominal, thyroid and breast examination
• Rough fundal height (in finger above symphysis units) if uterus is palpated (symphysis fundal height in cm not required under umbilicus)
• Bedside tests – urine bHCG, urinary dipstick
• Edinburgh Postnatal Depression Scale

It is important to remember that if a patient presents requesting an abortion, our common practices are still relevant and important. To merely provide a referral to the nearest abortion service is not necessarily good medical care. Rather, good medical care involves taking an appropriate history and physical examination of the patient, which both provide more information for decision-making, and also provide the opportunity to develop rapport with a patient whom you may not have met before.

A Practical Approach – Non-Directive Counselling

At this stage of the consultation, we begin the non-directive counselling. Pregnancy counselling is a legal part of seeking an abortion in most states. Different states also have different laws about what kind of abortion can be performed, by whom, at what gestations and for what reasons. It is necessary to have some idea of these for your state.

To do this counselling work, I personally recommend using a blank A4 piece of paper to document the opinions and thoughts that the woman has regarding her options. With the paper in landscape orientation, I title it “Pregnancy Options” and place three subtitles: “Keeping the pregnancy”, ”Adoption” and “Abortion”. It’s important to inform the patient of the different types of abortion, as well as the availability and complications (medical and surgical) of each. Ask the patient what their current thoughts are on which options they have already considered and the pros and cons for each option, including any emotional, physical, and financial consequences of each decision. These can then be written into the table. Also explore whether they have any risk factors for fertility; or, if they were to have fertility problems in the future, would that affect their decision now? Finally, talk about any support networks available to them in the local area, including those that would support them whether they were to, or not, proceed with abortion. An example sheet can be seen below:

Pros & Cons	Keeping Pregnancy	Adoption	Abortion – Medical and Surgical
PROS	– Having a baby – No guilt from abortion or difficulty from adoption	– No guilt from abortion – Better financial health	– Better financial health – What my partner wants – Allows me to continue university
CONS	– Financially costly – Not supported by my partner	– Difficult giving up child – Not supported by my partner	– Feeling guilty – Medical Complications

After this discussion, explain and emphasise that the patient has time to make a decision. Depending on their gestation and what jurisdiction you are in, often there are several weeks before a final decision needs to be made. Give the patient the diagram you have constructed together and suggest the patient discuss this with someone they trust, such as a mother, best friend, husband, or partner.

Finally, book another appointment to see them in a week and invite them to bring their trusted person with them. If they report they are Christian, or attend church, you could prayerfully consider offering prayer for them. If you do so, keep your prayer non-judgemental and supportive. Otherwise, pray for them in your own time. Consider sending a deidentified message to people you trust to pray for this woman and her family. 

What About the Baby?

During the consultation, it is important to perform the necessary investigations and initial management of pregnancy as outlined below. These will still be relevant even if she does choose abortion in the future.

• Initial minimum routine investigations:

  • Recommended

    • Quantitative bHCG, FBC, blood group and antibody screen, HIV/Hep B/Hep C/Syphilis, Rubella, random BSL

    • Urine M/C/S and Chlamydia/ Gonorrhoea PCR

  • Optional (depending on circumstances)

    • Early dating ultrasound (this can also be helpful for those requesting abortion in terms of urgency, timing, and options based on gestation)

    • CST if due

    • First Trimester Screening (or lack thereof) as chosen by patient

    • If risk factors – early oral glucose tolerance test, iron studies, haemoglobinopathy screening, vitamin D

When this woman re-presents in a week’s time, respect her choice. You can’t stop every abortion in Australia, just as you can’t stop all wrongdoing throughout the world. By engaging the women who attend, some of those coming, even those seeking abortion, may choose to keep their baby. If, as Christian doctors, we show compassion and empathy to women in these vulnerable situations, we will save some children, and I think that is what God asks of us. Personally, I don’t refer directly for abortion. I explain that due to my conscience I cannot make the referral and instead book them an appointment with a colleague. In some states, not referring is illegal, so you need to be aware of your local law. As an example, a Christian colleague in Victoria tells me he follows the law in referring, but states his objection to the performing of abortion in the referral. Ultimately, where you draw your lines as a Christian depends on your own conscience. I hope this practical guide helps prevent you from feeling overwhelmed. The next time a patient like this walks in the door, I hope you will see it as an opportunity to perhaps prevent an abortion that may have happened if they had seen another doctor.

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References:

1. Coombe J, Harris M, Wigginton B, Loxton D, Lucke J. Contraceptive use at the time of unintended pregnancy: Findings from the Contraceptive Use, Pregnancy Intention and Decisions study. Australian Family Physician. 2016 November; 45(11).
2. Taft A, Shankar M, Black K, Mazza D, Hussainy S, Lucke J. Unintended and unwanted pregnancy in Australia: a cross-sectional, national random telephone survey of prevalence and outcomes. Medical Journal of Australia. 2018; 209(9).
3. Department of Health. Department of Health and Aged Care – Pregnancy Support Counselling. [Online].; 2020 [cited 2022 August. Available from: https://www1.health.gov.au/internet/main/publishing.nsf/Content/health-pcd-pregnancy-support.htm.
4. Conjoint Committee for the Diploma of Obstetrics and Gynaecology. Certificate of Women’s Health Logbook Melbourne: Conjoint Committee for the Diploma of Obstetrics and Gynaecology; 2021.
5. ACRRM. Non-Directive Pregnancy Support Counselling. [Online].; 2022 [cited 2022 August. Available from: https://acrrm.instructure.com/courses/178.