Basic Concepts for Delivering Postabortion Care Unsafe abortion

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) 1

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 2

Basic Concepts for Delivering Postabortion Care The current state of PAC in many health clinics • • Medical equipment is obsolete or in poor condition Abortion patients are not treated with respect and sympathy Services are not well organized and supervision is poor Services are not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 3

Basic Concepts for Delivering Postabortion Care Potential difficulties in providing PAC services • • • 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 4

Basic Concepts for Delivering Postabortion Care Potential difficulties in providing PAC services (cont’d) • • • 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) 5

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

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 7

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 8

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 9

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 10

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 11

Basic Concepts for Delivering Postabortion Care 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? 12

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

Basic Concepts for Delivering Postabortion Care 14 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

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. 15

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. 16

Basic Concepts for Delivering Postabortion Care 17 Bimanual Exam

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. 18

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). 19

Basic Concepts for Delivering Postabortion Care 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. 20

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 21

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

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

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

Basic Concepts for Delivering Postabortion Care 25 Nerves that transmit pain T 12 L 1 L 2 L 3 L 4 Hypogastric plexus -body, fundus of uterus Uterus S 2 S 3 S 4 Cervix Vagina Uterovaginal plexus -cervix, upper vagina

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 26

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 27

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 28

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 29

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 30

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) 31

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

Basic Concepts for Delivering Postabortion Care 33 Paracervical block (cont’d) Optional Injection Sites • 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

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 lightheadedness 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 34

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 35

Basic Concepts for Delivering Postabortion Care 36 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.

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

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

Basic Concepts for Delivering Postabortion Care 39 Efficacy of MVA Treatment of Incomplete Abortion Studies Procedures Aspiration time Efficacy rate Adapted from Greenslade et al. 1993 19 >5, 000 Generally from 3 to 5 minutes >98%

Basic Concepts for Delivering Postabortion Care 40 Safety Rate of complications in vacuum aspiration (electric and manual) vs. D&C in abortion reported in JPSA study Type of procedure Percentage of women sustaining complications Total complications Serious complications Vacuum Aspiration 5. 0 0. 4 D&C 10. 6 0. 9 Adapted from Grimes et al. 1977

Basic Concepts for Delivering Postabortion Care 41 Average Number of Complications per 100 Procedures in Six Studies Comparing Vacuum Aspiration and Sharp Curettage Type of Procedure Averages Across Six Studies Excess Blood Loss Vacuum Aspiration Sharp Curettage Adapted from Baird et al. 1995. 5. 3 10. 8 Uterine Perforation 0. 13 0. 3 Averages Across Three Studies Pelvic Infection 3. 8 4. 5 Cervical Injury 1. 1 2. 9

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

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

Basic Concepts for Delivering Postabortion Care 44 Comparison: Treatment of incomplete abortion MVA D&C Efficiency Very efficient Efficient* Complications Lower rates Higher rates Cervical Dilation Occasionally required Usually required Pain Management Usually local anesthesia Often general anesthesia Service Delivery Site Usually treatment room Often operating room Hospital Stay Usually less than 6 hours Frequently more than 24 hours *Efficiency is defined as a successful uterine evacuation with no remaining tissue

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

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

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

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 10 cc 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

Basic Concepts for Delivering Postabortion Care 49 Selecting the cannula Approximate uterine size (weeks LMP) Approximate size of the cannula 5 to 7 LMP 4 to 6 mm 8 to 9 LMP 7 to 8 mm 10 to 12 LMP 9 to 12 mm Adapters for the double-valve syringe are color-coded to the dots on the corresponding cannula.

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

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

Basic Concepts for Delivering Postabortion Care Preparing MVA instruments (continued) • 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 52

Basic Concepts for Delivering Postabortion Care 53 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

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

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

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

Basic Concepts for Delivering Postabortion Care 57 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

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

Basic Concepts for Delivering Postabortion Care 59 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

Basic Concepts for Delivering Postabortion Care 60 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

Basic Concepts for Delivering Postabortion Care 61 Evacuating uterine contents • • • Do not grasp the syringe by the plunger arms! 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

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

Basic Concepts for Delivering Postabortion Care 63 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

Basic Concepts for Delivering Postabortion Care If the cannula has been withdrawn from the external os: 64 • 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 contamination occurs, use another cannula!

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

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

Basic Concepts for Delivering Postabortion Care 67 Recognizing and managing uterine perforation Signs: Instruments inserted beyond the fundus Excessive bleeding Fat or organ fragments in the aspirated tissue 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

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

Basic Concepts for Delivering Postabortion Care Inspecting the tissue • Follow protocols for infectionprevention • 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 69

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

Basic Concepts for Delivering Postabortion Care 71 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 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

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

Basic Concepts for Delivering Postabortion Care What the patient needs to know • • 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. 73

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

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. 75

Basic Concepts for Delivering Postabortion Care General recommendations • 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. 76

Basic Concepts for Delivering Postabortion Care Factors that can affect contraception selection • • 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 77

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

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? 79

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

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

Basic Concepts for Delivering Postabortion Care Contraception when trauma has occurred to the genital tract • 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. 82

Basic Concepts for Delivering Postabortion Care Contraception after hemorrhage • 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. 83

Basic Concepts for Delivering Postabortion Care 84 Contraception after second-trimester abortion • 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.