Where Women Have No Doctor - A Health Guide for Women (Hesperian Foundation, 1997, 600 p.) Chapter 15: Abortion and Complications from Abortion (introduction...) Why Do Some Women Have Abortions? Safe and Unsafe Abortion Deciding about an Abortion Safe Methods of Abortion (introduction...) How to tell if an abortion will be safe What to Expect during a Safe Abortion What to Expect after an Abortion Family Planning after an Abortion Complications of Abortion (introduction...) Heavy bleeding from the vagina Emergency help for too much bleeding Shock Infection Fainting or loss of consciousness Injury inside the body (Internal Injury) Preventing Unsafe Abortion

Where Women Have No Doctor - A Health Guide for Women (Hesperian Foundation, 1997, 600 p.)

Chapter 15: Abortion and Complications from Abortion

If family planning methods fail, safe and legal abortion is a woman’s safety net.

Figure

When a woman does something to end a pregnancy, this is called an ‘abortion’. We use the word abortion in this book only to describe an action that is planned. The unplanned, natural loss of a pregnancy we call a ‘miscarriage’.

¨ Lack of family planning services and lack of information about sex lead to unwanted pregnancy and abortion.

Deciding to have an abortion is always hard. A woman may seek abortion because:

· she already has all the children she can care for.
· a pregnancy is a danger to her health or her life.
· she has no partner to help support the child.
· she wants to finish school.
· she does not want to have children.
· she got pregnant after being forced to have sex.
· someone is forcing her to have an abortion.
· the child will be born with serious problems (birth defects).

Why Do Some Women Have Abortions?

Unplanned and unwanted pregnancy can happen when... ... the woman and her partner do not know how pregnancy happens. ... health workers think some women are too young to get family planning. ... women are forced to have sex. ... family planning is not available, is not used correctly, or it fails.

Emergency Family Planning Methods

A woman who has had unprotected sex within the last 3 days may be able to prevent pregnancy if she acts quickly.

Safe and Unsafe Abortion

A safe abortion is less likely to cause harm than having a baby.

Abortion is very safe when it is done:

· by a trained and experienced health worker.

· with the proper instruments.

· under clean conditions. Anything that goes into the vagina and womb must be sterile (without any germs).

· up to 3 months (12 weeks) after the last monthly bleeding.

Abortion is unsafe when it is done:

· by someone who has not been trained to do it.
· with the wrong instruments or medicines.
· under unclean conditions.
· after 3 months (12 weeks) of pregnancy, unless it is done in a health center or hospital that has special equipment.

DEATH FROM UNSAFE ABORTION

Around the world, 55 million abortions are done every year. Women survive most of them, even if they are not legal. But unsafe abortions can cause death, or complications like infection, lasting pain, and infertility.

Out of 100,000 women getting a safe abortion, only I will die.

Figure

But out of 100,000 women having unsafe abortions, between 100 and 1000 will die.

Figure

¨ Avoid unsafe abortion. Try to prevent unwanted pregnancy before it happens.

Women have always tried to find ways to end pregnancy when they are desperate. Stay away from the following methods. They are very dangerous.

· Do not put sharp objects like sticks, wire, or plastic tubing into the vagina and womb. These can tear the womb and cause dangerous bleeding and infection.

· Do not put herbs or plants in the vagina or womb. These can burn or irritate badly, causing damage, infection, and bleeding.

· Do not put substances such as bleach, lye, ashes, soap, or kerosene in the vagina or womb. Also, do not drink them.

· Do not take medicines or traditional remedies in large amounts to cause abortion (either by mouth or in the vagina). For example, taking too much of the medicines for malaria (chloroquine) or to stop bleeding after childbirth (ergometrine, oxytocin) can kill you before they cause abortion.

· Do not hit your abdomen or throw yourself down stairs. This can cause injury and bleeding inside your body, but may not cause abortion.

IMPORTANT
Never put anything inside the womb yourself or allow an untrained person to do so. This can kill you.

ACCESS TO SAFE ABORTION

When a woman is faced with an unwanted pregnancy, she should be able to get a safe and legal abortion. But laws about abortion differ from one country to another

Legal abortion. If abortion is legal a woman can walk into a health center or hospital, pay a fee, and have a safe abortion. In countries where this happens, almost no women get sick or die from complications of abortion.

Legal abortion in some cases. In some countries an abortion is only legal for certain reasons, such as:

· if a woman becomes pregnant from rape or incest (sex with a close family member).
· if a doctor says pregnancy would be a danger to a woman’s health.

But abortion is often difficult to get, even for those reasons. Doctors and health workers may not be sure what the law really says. They may be unwilling to do abortions openly, or they may charge a lot of money. Women may not know if abortion is legal or available in their country.

¨ Even if abortion is illegal, a woman should be able to get medical help for complications after an abortion. It is often difficult to tell the difference between abortion and miscarriage, unless something from the abortion has been left in the womb.

Illegal abortion. If abortion is not legal, both the women who get abortions and those who perform them can be arrested.

In most places this does not happen. But where abortion is against the law, more women die from unsafe abortion and unsafe pregnancies. Money that could be spent on women’s health services is spent instead on treating complications of unsafe abortion.

Never assume abortion is illegal. Try to find out about the laws in your own country. It may be easier to work around the laws than to try and change them. Even if abortion is illegal, there may be people providing safe abortions. Finding a safe abortion may mean the difference between staying alive and dying.

Other barriers to finding a safe abortion Legal or not, it can be hard to get a safe abortion because it is too costly, too far away, or because there are confusing rules, or papers to fill out. Figure These reasons often make it especially difficult for women who are poor, or who are not familiar with the medical system, to get safe abortions. Unfortunately, in many places, the only women who can easily get a safe abortion are women who can afford to pay a private doctor.

Deciding about an Abortion

¨ If safe abortion is not available, you might consider giving the baby up for adoption, if this is acceptable to you and your community.

Your decision to have an abortion will often depend on whether safe abortion is available where you live. It also depends on how an abortion or a baby would affect your life.

Figure

It may help to think about these questions:

· Will you be able to care for a baby? Do you have enough money to raise a child?

· Is pregnancy a danger to your health?

· Do you have a partner or husband who will help support a child? Can you talk with him about this decision?

· Is your religion or family against abortion? If yes, how will you feel if you have one?

· How will the abortion be done?

· For how long have you been pregnant?

· Could you have a sexually transmitted disease (STD)? You may be at more risk of having an STD if you are young, single, and have a new partner, or if you have signs of an STD. If you feel that you are at risk, see the STD chapter. You may need treatment before the abortion.

· What complications (problems) can be caused by the abortion?

· Where can you go for emergency care if you have complications? How will you get there?

Figure

The information on the next pages may help you decide whether safe methods of abortion are available in your community.

If you are helping someone decide about an abortion: Figure She needs respectful advice and friendly support. Do not tell anyone else about her decision unless she wants others to know.

Safe Methods of Abortion

A pregnancy can be removed from the womb by a trained health worker in the following ways:

Abortion by suction (vacuum aspiration, MVA)

The pregnancy is removed by suction using a special tube (cannula) that is put into the womb through the vagina and cervix. This can be done without putting the woman to sleep, though sometimes medicine is injected into the cervix to help with the pain. When vacuum aspiration is done by hand (manual vacuum aspiration or MVA), the pregnancy is removed using a special syringe. Otherwise, a small electric machine is used.

Cannula

Vacuum aspiration is simple and safe, and takes only about 5 to 10 minutes. It is usually done in a clinic or health post, or doctor’s office. This kind of abortion is easiest to do during the third month of pregnancy, but is sometimes done a bit later Vacuum aspiration causes fewer complications than dilation and curettage (described below).

Vacuum aspirator

In some places MVA is used to bring on late monthly bleeding. The woman may not even know if she is pregnant - just that her monthly bleeding has not come. This is called menstrual regulation.

Abortion by scraping (dilation and curettage, or D and C)

The pregnancy is scraped out with a curette, a small spoon-shaped instrument that is made especially to go into the womb. A curette is larger than a cannula and because it is sharp, the cervix must first be stretched open. This stretching can cause some pain.

Curette

The D and C takes more time to do (about 15 to 20 minutes), is more painful, and costs more than vacuum aspiration. It is usually done in an operating room, and the woman is often given medicine to make her sleep.

Abortion by medicine (medical abortion)

Certain medicines are now being used by doctors and health workers to cause abortion. These medicines work by causing the womb to contract and squeeze out the pregnancy. Some medicines are put into the vagina (NOT in the womb), some are swallowed, and some are injected. If the right medicine to cause abortion is used, it may be safer than putting something inside the womb, which may cause severe injury or infection.

¨ As time goes on, medicines for abortion may be used in more places and be more available to women who need them.

If you use medicines for abortion · Never use a medicine you are not sure of. · Medicines to cause abortion should only be used if there is a health clinic or hospital close by, so you can get there soon after bleeding starts. The clinic or hospital should have trained health workers who can empty a womb in case the abortion medicines do not work. · Go to the clinic or hospital when bleeding starts so your womb can be checked to see if it has emptied completely. If it has not, you must have the rest of the pregnancy removed by suction or scraping. If you do not, you could suffer dangerous complications. (If you go on to give birth, the baby may be born with severe birth defects.)

Some medicines used for abortion

1. Mifepristone (RU-486, the ‘French Pill’) is available in some countries to cause abortion in women who are up to 9 weeks pregnant. It is given only in special programs in clinics and hospitals where the woman can be watched for complications and treated if needed. Two days later a second medicine, such as misoprostol, is given. This usually causes complete abortion.

2. Misoprostol is a medicine used to treat stomach ulcers, and is used with mifepristone or other medicines to cause abortion. It can also be used by itself to start abortion, but usually the abortion will not finish, so a woman must get medical care after bleeding starts. Misoprostol can be used during the first 3 months (12 weeks) of pregnancy, and works better close to 12 weeks. The tablets are put into the vagina, not swallowed.

3. Methotrexate is an anti-cancer medicine which has been used together with misoprostol to cause abortion. It has dangerous side effects for the woman, and if it fails to cause abortion, it can cause severe birth defects in the baby. Not enough is known yet about how to use methotrexate safely, especially in places without modern hospital equipment.

IMPORTANT
Follow the instructions for misoprostol very carefully. If you do not, the womb can split open (rupture) and cause death.

Figure

¨ For more information about these medicines, see the Green Pages

Incomplete abortion An incomplete abortion is when part of the pregnancy remains in the womb after an abortion. The signs are heavy bleeding for more than one day after the abortion, cramping pains, and passing tissue and clots or lumps of blood from the vagina. If this happens, go to a hospital right away to have the pregnancy completely removed. If not, you could have serious complications and even die. See What to Expect after an Abortion for danger signs after abortion.

How to tell if an abortion will be safe

It is not always easy to tell if an abortion will be safe. Try to go to the place where the abortion will be done, or ask someone who has been there these questions: · Have you heard of women getting sick or dying from having an abortion here? If so, go somewhere else. · Who will do the abortion and how were they trained? Doctors, nurses, health workers, and traditional birth attendants can all do abortions. However, abortions done by someone who is not trained in safe abortion methods and how to prevent infection can be very dangerous. This room looks safe. · Is the room where the abortion will be done clean and neat? If it is dirty and messy, probably the abortion will be also. · Is there a place for washing hands? A health worker who has no place to wash his or her hands cannot do a clean, safe abortion. · Do the instruments look like the ones in this chapter on Safe Methods of Abortion, or do they look like something found or made at home? Instruments made at home can cause injury and infection. · How are the instruments cleaned and made free of germs? Instruments should be soaked in strong disinfectant or boiled in water to kill germs that cause infection. · Does the cost seem fair? If the cost is very high, sometimes it means the health worker cares only about money, not your health. · Are other health-care services also provided along with abortions? A good health center will also try to provide other services that women need, like family planning, treatment for STDs, and AIDS prevention. · Where will you be taken if something goes wrong during or after the abortion? There should always be a plan to get you to a hospital in case of emergency. This room does not look safe.

IMPORTANT An abortion is more dangerous if: · your last monthly bleeding was more than 3 months ago. · your pregnancy is starting to show. Figure The longer you have been pregnant, the greater the chance of complications after abortion. For your safety, an abortion after more than 3 months of pregnancy must be done with special equipment in a clinic or hospital.

What to Expect during a Safe Abortion

Safe abortions, especially abortions by suction (MVA), are done in both health centers and hospitals. An abortion by scraping (D and C) is usually done in a hospital. An abortion by medicine should be done at a health center or hospital that also has equipment to do MVAs and D and Cs, and health workers trained to do them. For more information about how these abortions are done, see Safe Methods of Abortion.

¨ Drink plenty of liquids the day before you have an abortion. This will help you recover more quickly.

When you go to a health center or hospital for an abortion, you should be welcomed and treated with respect. A counselor should talk with you about your decision and explain how the abortion will be done and what the risks are.

Figure

The information below tells what to expect from a safe abortion. An abortion that - is very different from this could be dangerous.

· You should be asked about the time of your last monthly bleeding and whether you might have an STD.

· A health worker should do a medical exam. This includes feeling carefully in your vagina and on your belly for the size of your womb.

· During both abortion by suction and by scraping you will feel strong pains in the lower belly. But soon after the abortion is over, the pains will become less strong.

· After the abortion, your genitals should be cleaned, and then you should be taken to rest. A health worker should be there to check you for about an hour.

· Someone should tell you what to do after the abortion, the danger signs to watch for, and who to contact if you have a complication.

Figure

In addition, someone should discuss family planning methods with you. You can start using a method the day of the abortion. You should be given an appointment to come back for a check-up in 1 or 2 weeks.

What to Expect after an Abortion

After an abortion, signs of pregnancy, like nausea and sore breasts, should disappear within a day. If they do not, you could still be pregnant, either in your womb or in one of your tubes (ectopic pregnancy). This is an emergency. See a health worker right away.

You may feel a little tired and have some cramps or pains for a day after the abortion. You will have some bleeding from the vagina for as long as 2 weeks. But after the first day it should be no more than a light monthly bleeding. Your next normal monthly bleeding should start about 4 to 6 weeks after an abortion. It might take longer if you were more than 5 to 6 months pregnant.

¨ Normal monthly bleeding should start about 4 to 6 weeks after an abortion. But you can become pregnant again after 11 days.

If you had no one to talk to before the abortion, it may help to talk to someone now. Talking about your feelings with someone you trust can make you feel better.

How to care for yourself after an abortion:

· To prevent infection, take 100 mg of doxycycline twice a day for 5 days starting the day of the abortion. (But if you are breastfeeding, take 500 mg of amoxicillin 3 times a day for 5 days instead.)

· Do not have sex or put anything into your vagina for at least 2 days after bleeding stops.

· If you have cramps or pains, rest and use a hot water bottle on your abdomen. Or take paracetamol or ibuprofen.

· To lessen pain and bleeding, rub or massage your lower abdomen often. This helps the womb to squeeze down to normal size and lessen bleeding.

· Drink plenty of liquids to help you recover faster.

· You can go back to your usual activities as soon as you feel well, usually within a day.

After an abortion, start family planning right away. You can get pregnant again before your next monthly bleeding.

Danger signs If you have any of these signs, get medical help fast: · Heavy bleeding from the vagina (see Complications of Abortion) · High fever (see Infection) · Severe pain in the abdomen (see Internal Injury and Infection) · Fainting and confusion (see Shock) · Bad-smelling discharge from the vagina (see Infection)

Family Planning after an Abortion

After an abortion you can get pregnant again right away - in as soon as 2 weeks. Many methods of family planning take time to start working, so talk with someone about family planning and start using one of these methods as soon as possible:

· The Pill: You can start taking pills on the same day as the abortion. Do not wait more than one week.

Figure

· Intra-Uterine Device (IUD): If there is no risk of infection, a trained health worker can put in an IUD right after the abortion.

Figure

· Injections: The first injection should be given on the day of the abortion, or up to one week after.

Figure

· Implants: Implants can be put in just before or just after the abortion, or up to one week later.

¨ A woman who has just had an abortion most likely did not want to become pregnant. This is a good time to offer her information about family planning methods and how to get them.

· Female sterilization: If your pregnancy was less than 3 months, you can be sterilized during the abortion or right after it. It is very important that you make this decision carefully. Sterilization is permanent.

· Male sterilization: Sterilization for a man can be done any time and is permanent. This decision must be made carefully.

· Condoms: You and your partner can use condoms as soon as you have sex again. Condoms also protect against STDs, including HIV.

Figure

· Spermicide: You can use spermicide as soon as you have sex again. Spermicides made with nonoxynol-9 also give some protection against gonorrhea and chlamydia, 2 common STDs.

Figure

· Diaphragm: If there was no infection or injury, you can be fitted with a diaphragm before or after the abortion. Diaphragms with spermicide give some protection against gonorrhea and chlamydia.

Figure

· Natural methods (mucus and rhythm): These methods do not work until your normal monthly bleeding returns.

Figure

¨ For more information on all these methods, see the chapter on “Family Planning.”

Complications of Abortion

A woman with any of the danger signs after abortion needs medical help fast! She should go immediately to a health center or hospital where she can get the care she needs. Most of the time the womb must be emptied completely using vacuum aspiration or a D and C. In the meantime, the information on the next pages may help if transport is not available immediately or if medical care is very far away.

¨ Early treatment of abortion complications prevents illness, infertility, and death. Seek help quickly if you have problems after an abortion. DO NOT WAIT!

Heavy bleeding from the vagina

Heavy bleeding is the most common problem after an abortion. It is usually caused by pieces of the pregnancy that are left in the womb. The womb cannot squeeze itself shut and keeps bleeding. If the pieces are removed, often the bleeding will stop. Sometimes the bleeding is caused by a torn cervix which must be stitched for the bleeding to stop.

Figure

A woman is bleeding too much if she soaks a pad, towel, or clothing with bright red blood in less than 30 minutes. A slow, steady trickle of bright red blood is also dangerous. When this happens, a woman may quickly lose a dangerous amount of blood. If it is not possible to get medical help immediately, try to stop the bleeding.

To stop the bleeding

A woman who is bleeding too much may be able to help her womb squeeze shut with massage. She can do this herself or have someone else do it. Rub or massage the lower belly very hard while lying down or squatting.

Figure

If there are pieces of tissue stuck in the womb or cervix, she may be able to push them out herself by squatting and bearing down as if passing stool or giving birth.

Even if these treatments seem to work, get medical help as soon as possible. The woman will need antibiotics and may still need to have her womb emptied completely.

Emergency help for too much bleeding

Health workers and others trained in giving a woman a pelvic exam may be able to follow these steps to try and stop the bleeding until the womb can be emptied.

IMPORTANT
Because the entrance to the woman’s womb is open, putting anything inside her vagina is very dangerous. She can get a serious infection. Only do this if the bleeding is so heavy the woman’s life is in danger. See the previous page for how much bleeding is too much.

1. Wash your hands and the woman’s genitals with soap and clean water

Figure

2. Put a clean latex or plastic glove or a very clean plastic bag on one hand. The gloved hand should not touch anything before it goes into the woman’s vagina.

Figure

3. Have the woman lie on her back with her feet and knees apart. Help her relax.

Figure

4. If you have a sterile speculum (you can get the right instruments from an IUD kit if you have one), put it into the vagina so you can see the opening of the womb. If you can see tissue or clots or lumps of blood there, try to get hold of them with sterile forceps or clamps and gently remove them.

Use sterile forceps to remove any tissue you see at the opening of the womb.

5. If you do not have a speculum, reach inside the woman’s vagina with your gloved hand, first with 1 finger, and then with 2 fingers.

6. Feel for the cervix. It will feel more firm and smooth than the skin around it. It looks like this and is about this size.

Figure

7. Move your finger across the opening and feel for bits of the pregnancy that may be sticking out of the opening. They will feel like soft meat. Gently try to remove them. If the pieces are too slippery, take your hand out and wrap 2 fingers with sterile gauze, or a clean cloth that has been boiled in water, and try again to remove them.

Figure

8. After you have removed the pieces, put your gloved hand into the woman’s vagina with two fingers under the womb. With your other hand, rub or massage her belly to help stop the bleeding. Her womb should be between your 2 hands.

Figure

9. Give the woman an injection of ergometrine (0.2 mg) in a large muscle, such as her buttock or thigh. Then give her one 0.2 mg pill of ergometrine, or a 0.1 mg injection, every 4 hours for 24 hours.

Figure

10. Give antibiotics for mild infection immediately to prevent infection. She is at high risk of infection because the womb is open to germs.

11. If she is awake, give her fluids to drink. If she is unconscious, see the next page.

12. Take her to a hospital right away, even if you think you have removed the tissue and the bleeding has stopped. She still needs to have her womb emptied completely. If the bleeding does not stop, continue to rub or massage her lower belly while taking her to the hospital.

When there is no health worker to help If you are bleeding too much after an abortion, you can also try to remove tissue stuck in your cervix by yourself. Figure First wash your hands and genitals well with soap and clean water. Then squat and bear down, as in childbirth or passing stool, and follow the instructions above in steps 6 and 7. After you have removed any pieces, massage your lower belly. You should still get medical help, even if the bleeding becomes less.

Shock

Shock is a life-threatening condition that can result from heavy bleeding. Bleeding inside the body can also cause shock.

DANGER! Heavy bleeding can cause SHOCK, which can kill. Transport immediately.

Signs:

· very fast heart rate, more than 110 beats a minute
· pale, cold, damp skin
· pale inner eyelids, mouth, and palms
· fast breathing, more than 30 breaths a minute
· confusion or unconsciousness (fainting)

Treatment if she is conscious:

· Lay the woman down with her feet higher than her head.
· Cover her with a blanket or clothes.
· If she can drink, give her sips of water or rehydration drink.
· Help her to stay calm.
· If you know how, start a fast intravenous drip (IV) with a wide needle, or start rectal fluids.

Figure

Treatment if she is unconscious:

· Lay her on her side with her head low, tilted back and to one side, and her feet high.

Make sure her feet are higher than her head.

· If she seems to be choking, pull her tongue forward with your finger.

· If she has vomited, clean out her mouth immediately. Be sure her head is low, tilted back and to one side, so she does not breathe vomit into her lungs.

· Do not give her anything by mouth until she has been awake for one hour

· If you know how, start a fast IV drip with a wide needle. If you do not, start rectal fluids.

Do not wait for a health worker. Take the woman for medical help or to a hospital right away. She needs medical help fast!

Infection

If there is infection, it is more likely to be a mild infection if the abortion was done sooner than 3 months (12 weeks) after the last monthly bleeding.

Serious infection is an infection that has spread into the blood (sepsis). A woman is more likely to have a serious infection if the abortion was done later than 3 or 4 months from the last monthly bleeding, or if there was an injury to the womb during the abortion. Sepsis is very dangerous and can also cause shock.

Infection can happen because:

· an unclean hand or object was put inside the womb.
· pieces of the pregnancy were left inside the womb and they have become infected.
· the woman already had an infection when she had the abortion.
· a hole was made in the wall of the womb.

Signs of mild infection:

· slight fever
· mild pain in the abdomen

Figure

Treatment for mild infection:

To keep mild infection from becoming serious, treat it immediately with the medicines listed below. A woman needs more than one medicine because infections after abortion are caused by several different kinds of germs. If the medicines listed below are not available, see the “Green Pages” for others that will work. A woman who is breastfeeding should use the treatment for womb infection after childbirth.

Medicines for mild infection after abortion
Medicine	How much to take	When and how to take
Take both medicines:
amoxicillin	3 grams	all at once, 1 time only, by mouth
and
doxycycline	100 mg	2 times a day for 10 days, by mouth
IMPORTANT If the fever is not completely gone in 48 hours (2 days after starting these medicines), the woman should go to a health center.

Signs of serious infection:

· chills and high fever
· muscle aches, weakness, and tiredness
· swollen, hard, and painful belly
· bad-smelling discharge from the vagina

Figure

Treatment for serious infection:

· Take the woman to a health center or hospital immediately.

· Start the following medicines right away, even if you are already on your way to the hospital. If she can swallow, give her these medicines, with plenty of water:

Medicines for serious infection after abortion
Medicine	How much to take	When and how to take
Take all 3 medicines:
amoxicillin	3 grams	all at once, 1 time only, by mouth
and
doxycycline	100 mg	2 times a day by mouth until you reach a hospital
and
metronidazole	500 mg	3 times a day by mouth until you reach a hospital

If the woman cannot swallow medicines and you know how to give injections or IV medicines, start giving the medicines listed on the next page. But do not delay. Take the woman for medical help or to a hospital right away. She needs medical help fast.

TETANUS A woman with an infection or bleeding from an injury after abortion can get a tetanus infection, especially if a dirty object or instrument was put into her womb. She needs a tetanus toxoid vaccination immediately. Figure

Injectable medicines for serious infection after abortion IMPORTANT Medicines in the vein (IV) or in the muscle (IM) should be given until the woman has been completely without fever for 48 hours. · Choose one box and give ALL the medicines in that box. · If the woman still has fever after 24 hours, change to another group of medicines. · After 48 hours without fever, she can change to medicine by mouth (see the box). For complete information on these medicines, see the “Green Pages.”
Best treatment: Give all 3 medicines
Medicine:	How much to give:	When and how to give:
benzylpenicillin	5 Million Units	4 times a day, IV
gentamicin	80 mg first dose, then 60 mg each dose	3 times a day, IM
metronidazole	1 gram	2 times a day, by mouth or IV
Second best treatment: Give both medicines
Medicine:	How much to give:	When and how to give:
doxycycline	100 mg	2 times a day, by mouth or IV
metronidazole	1 gram	2 times a day, IV or by mouth
Third best treatment: Give both medicines
Medicine:	How much to give:	When and how to give:
benzylpenicillin	5 Million Units	4 times a day, IV
chloramphenicol	1 gram	4 times a day, IV
After 48 hours without fever, give this medicine by mouth:
Medicine:	How much to give:	When and how to give:
doxycycline	100 mg	2 times a day, by mouth, for 10 days
If a woman is breastfeeding, give amoxicillin instead, 500 mg 3 times a day for 10 days.

Fainting or loss of consciousness

Figure Fainting can be a sign of shock after abortion, either from heavy bleeding, severe injury to the internal organs, or infection. For signs and treatment of shock, see Shock. If a woman faints but wakes up very soon afterward and does not have signs of shock, give her plenty of liquids to drink and watch her carefully.

Injury inside the body (Internal Injury)

An internal injury from an abortion is most often caused by a sharp object that makes a hole in the womb. The object may also cause damage to other internal organs, such as the tubes, ovaries, intestines, and bladder.

When a woman has internal injuries she may have severe bleeding inside her abdomen but almost no bleeding from her vagina.

Signs (she will have some or all of these):

· her abdomen feels stiff and hard with no sounds or gurgles inside
· very bad pain or cramps in the abdomen
· fever
· nausea and vomiting
· pain in one or both shoulders

Listen for gurgles for 2 minutes.

Treatment:

· Immediately take the woman to a hospital or clinic where she can have surgery. An injury inside the body must be repaired right away by a surgeon or it can lead to infection, shock, and death.

· Do not give her anything by mouth - no food, no drink, not even water - unless it will take more than I 2 hours to get to a health center. Then give water only in small sips. Or let her suck on a piece of cloth soaked in water.

· If she has signs of shock, treat her for shock. Make sure nothing is blocking her mouth and that she can breathe.

· Give her the medicines for severe infection, but only by injection or IV. If possible, give her a tetanus toxoid vaccination.

Preventing Unsafe Abortion

Family planning education can prevent the need for abortion.

Here are some things any woman or group of women can do in a community to help prevent illness and death from abortion:

· Educate men, women, and the community about how family planning can help prevent the need for abortion. Get training to provide family planning services to women in your community.

· Educate women and girls in your community about the dangers of unsafe abortion.

· Visit the people in your community who do abortions to make sure they are doing them safely.

· Learn about the complications of abortion and what to do for them. Find out where to take a woman in your community for emergency treatment of complications.

· Find out who could transport a woman who needs emergency care. If there is no emergency medical transport, is there someone in the community with a car or truck? Store extra containers of fuel (gas or petrol) for emergencies.

· Keep some of the medicines in a village pharmacy or clinic to treat emergency abortion problems.

If you are a health worker, here are some more suggestions:

· Try to get trained to do MVA, so you can treat women with abortion complications. Perhaps someone can train health workers at your local hospital. Do not do abortions unless you have been trained and have the instruments to do them safely.

· Organize health workers in your community to talk with health authorities about the risks of unsafe abortion. Even where abortion is not legal, treatment for abortion complications should be available to save women’s lives.

¨ Encourage women who are sick to seek help after an abortion, not to hide from it.

Treat women who need your help with kindness Many women who seek help after abortion are refused treatment or treated very badly. Some are made to feel ashamed or are given no care as ‘punishment’ for what they have done. Whatever your own beliefs, try not to judge women who have had an abortion, but rather care for them with compassion. Many of us could have an unwanted pregnancy at some time in our lives. Treat others as you would want yourself or your daughter to be treated.