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Abortion Care Clinical Guidelines

The document outlines interim clinical guidelines for abortion care in Western Australia, detailing the legal framework established by the Public Health Act 2016 and the Abortion Legislation Reform Act 2023. It provides guidance for healthcare professionals on performing abortions, including responsibilities, consent, and considerations for various patient circumstances. The guidelines aim to enhance access to abortion services while ensuring compliance with legal and ethical standards.

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0% found this document useful (0 votes)

21 views79 pages

Abortion Care Clinical Guidelines

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INTERIM WA Abortion Care

Clinical Guidelines
ONLINE CONSULTATION AND
ENGAGEMENT VERSION
(PRIOR TO QUEENSLAND HEALTH LICENCE APPLICATION)

Consultation approval date: 28 October 2024

Contents
Applicability ............................................................................................................................................................................. 4
Guideline statement ............................................................................................................................................................... 4
Relationship to parent policy ............................................................................................................................................... 4
Guideline details...................................................................................................................................................................... 6
Acknowledgement of Country and People .................................................................................................................... 6
Corporate acknowledgement and endorsements ........................................................................................................ 6
Disclaimer ............................................................................................................................................................................. 6
Recommended citation: ................................................................................................................................................. 7
Contact: ................................................................................................................................................................................. 7
Summary of Abortion Healthcare under the Public Health Act 2016 (the Act) ..................................................... 8
Medical Abortion with MS – 2 Step ................................................................................................................................ 9
Section 1: Western Australian Law ............................................................................................................................... 10
1.1 Performing an abortion ......................................................................................................................................... 10
1.2 Registered healthcare practitioner responsibilities ......................................................................................... 11
1.3 Assisting by a registered health practitioner or student ................................................................................ 12
1.4 Conscientious objection ....................................................................................................................................... 13
1.5 Emergency care involving abortion .................................................................................................................... 14
1.6 Safe access zones ................................................................................................................................................... 14
1.7 Non-compliance with the Act.............................................................................................................................. 15
Section 2 Clinical standards ............................................................................................................................................ 16
2.1 Service provision .................................................................................................................................................... 16
2.2 Workforce support ................................................................................................................................................ 18
Section 3 Individual case considerations...................................................................................................................... 19
3.1 Consent .................................................................................................................................................................... 19
3.2 Young person less than 14 years ........................................................................................................................ 22
3.3 Suspicion of child harm and exploitation .......................................................................................................... 22
3.4 Sexual Assault, Family, Domestic and Intimate Partner Violence and Reproductive Coercion ............. 23
3.5 Female genital mutilation ..................................................................................................................................... 25
3.6 Documentation of decisions ................................................................................................................................ 25
3.7 Suspected fetal abnormality ................................................................................................................................ 26
Section 4: Pre-abortion assessment .............................................................................................................................. 27
4.1 Psychological support ........................................................................................................................................... 29
4.2 Method selection ................................................................................................................................................... 32
Section 5: Medical and Surgical abortion risks and complications.......................................................................... 34
Section 6: Fetal considerations ...................................................................................................................................... 36
6.1 Birth registration .................................................................................................................................................... 36
6.2 Transport and management of fetal remains ................................................................................................... 37
6.3 Other fetal considerations ................................................................................................................................... 38
Section 7: Medical abortion ............................................................................................................................................ 39
7.1 Practitioner requirements .................................................................................................................................... 39
7.2 Medical abortion precautions .............................................................................................................................. 39
7.3 Early medical abortion in the outpatient setting ............................................................................................. 40
7.4 Early Medical Abortion pre-dosage care ........................................................................................................... 41
7.5 Early Medical Abortion at 63 days gestation or less....................................................................................... 42
7.6 Medical abortion after 63 days gestation ......................................................................................................... 43
Section 8: Surgical abortion ............................................................................................................................................ 45
8.1 Surgical abortion pre-procedure care ................................................................................................................ 45
8.2 Cervical priming for surgical abortion ................................................................................................................ 45
8.3 Surgical abortion of pregnancy ........................................................................................................................... 47
Section 9: Medical and Surgical post-abortion care................................................................................................... 49
9.1 Contraception ......................................................................................................................................................... 49
9.2 Discharge preparation and follow-up ................................................................................................................ 50
Definitions .............................................................................................................................................................................. 53
Abbreviations ..................................................................................................................................................................... 53
Definition of terms............................................................................................................................................................ 53
Document History ................................................................................................................................................................ 56
National Safety and Quality Health Service standards ................................................................................................ 56
Appendices ............................................................................................................................................................................. 57
Appendix A: Osmotic dilators for surgical priming prior to surgical abortion....................................................... 57
Appendix B: Aboriginal Clients: Cultural Considerations .......................................................................................... 59
Appendix C: Culturally Diverse Clients: Cultural Considerations............................................................................ 61
Appendix D: Family and Domestic Violence (FDV) Pathway................................................................................... 62
Appendix E: Acknowledgements ................................................................................................................................... 63
Appendix F: References ................................................................................................................................................... 66
Applicability
This guideline must be considered by:
• Health professionals working within the Western Australian Department of Health and Health
Service Providers.

Guideline statement
Abortion under the Public Health Act 2016 (WA) 1 means to perform an act with the intention of causing the
termination of a person’s pregnancy.
The purpose of this guideline is to assist healthcare professionals to provide care to people requesting
an abortion. This can be either a woman, a girl, or a pregnant person.
This guideline is set by the Heath Network Directorate and Clinical Excellence Division in accordance
with the Act. Registered health practitioners must have regard to the Public Health Act in the
performance of abortions.

Relationship to parent policy

On 27 March 2024, the Abortion Legislation Reform Act 2023 (WA) 2 came into effect in Western Australia.

The Reform Act repeals all provisions related to abortion within the Health (Miscellaneous Provisions) Act
1911 (WA) and creates a new framework relating to abortion under Part 12 C of the Public Health Act 2016
(WA), including to regulate the performance of abortion by registered health practitioners and prohibit the
performance of abortion by certain persons. Consequential amendments have also been made to the
Criminal Code, Children’s Court Act, Coroner’s Act, Freedom of information Act 1992 and the Guardianship
and Administration Act.

The new legislation aims to promote equity and reduce barriers for women, girls and pregnant people
accessing abortion care services in Western Australia.
Key changes implemented by the legislation include:

• Raising the gestational age limit for when abortion can occur, without additional requirements, from
20 weeks to ‘not more than 23 weeks.
• Removal of the mandatory counselling requirement prior to obtaining patient’s consent to the
abortion.
• Removal of the requirement for 2 medical practitioners to be consulted separately and consent
before a patient can have an abortion for certain gestational periods. The legislation allows one
health practitioner to be involved in an abortion (at not more than 23 weeks). The health practitioner
is required to obtain informed consent in line with existing standards of care.
• For a patient who is more than 23 weeks pregnant (23 weeks and 1 day gestation or more), an
abortion may be performed by a medical practitioner (the primary practitioner) if the primary
practitioner having fully considered all relevant medical circumstances, current and future physical,
psychological, and social circumstances and professional standards and guidelines, considers
performing the abortion appropriate in all circumstances. The primary practitioner must have
consulted with at least one other medical practitioner who, having also taken into account the above
considerations, reasonably believes that performing the abortion is appropriate in all the
circumstances.
• Registered health practitioners are able to conscientiously object to providing abortion services but
are required to refer a patient requesting an abortion to a provider or service that can provide
abortion care or provide the patient with information approved by the Chief Health Officer specifying

4
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This guideline has been developed for WA Health practice setting only. Clinical content is intended to guide clinical practice and does not replace clinical judgement. Modification will occur according to
internal audit processes and literature review. The rationale for the variation from the guideline must be documented in the clinical record.
how the patient can access an abortion.
• Approval from a Ministerial Panel is no longer required for late term abortions.
• Babies born alive as a result of an abortion and subsequently die are no longer reportable deaths to
the Coroner.

For copies of the Abortion Legislation Reform Act 2023, visit WALW - Abortion Legislation Reform Act 2023
- Home Page

5
PRINT WARNING – Content is continually being revised. ALWAYS refer to the electronic copy for the latest version. Users must ensure that any printed copies of this document are of the latest version.
This guideline has been developed for WA Health practice setting only. Clinical content is intended to guide clinical practice and does not replace clinical judgement. Modification will occur according to
internal audit processes and literature review. The rationale for the variation from the guideline must be documented in the clinical record.
Guideline details
Acknowledgement of Country and People
WA Health acknowledges the Aboriginal people of the many traditional lands and language groups of
Western Australia. It acknowledges the wisdom of Aboriginal Elders both past and present and pays
respect to Aboriginal communities of today.

Corporate acknowledgement and endorsements

The WA Department of Health acknowledges the North Metropolitan Health Service, Women’s and
Newborns Health Service (NMHS/WNHS) Abortion Care Working Group and stakeholders who developed
the Draft Abortion Care Clinical Guidelines, endorsed by the NMHS/WNHS Abortion Care Steering
Committee in March 2024.

The Draft Abortion Care Clinical Guidelines (INTERIM WA guidelines) were provided to the WA Department
of Health, Health Networks Directorate, Clinical Excellence Division for application and stewarding a
statewide license with Queensland Health. The Clinical Lead, Women and Newborn Health Network has
endorsed the INTERIM WA guidelines. Noting, addition of culturally appropriate Aboriginal and Culturally
and Linguistically Diverse consumer perspectives for care considerations, would strengthen the guidelines.

On 1 November 2024, the Draft for Consultation Abortion Care Clinical Guidelines is this version released
for consultation with WA health professionals. It builds on the INTERIM WA guidelines by including the
cultural consideration statements for Aboriginal clients, and for Culturally and Linguistically Diverse clients.
The WA Department of Health considers this version completed and prepared for submission to
Queensland Health for the statewide license. The online consultation process will identify any areas for
improvement, or editing, based on the feedback from WA health professionals who provide, or work in,
services providing abortion care.

Disclaimer
These guidelines are intended as a guide and provided for information purposes only. The information
has been prepared using a multidisciplinary approach with reference to the best information and
evidence available at the time of preparation. No assurance is given that the information is entirely
complete, current, or accurate in every respect.
The guidelines are not a substitute for clinical judgement, knowledge and expertise, or medical advice.
Variation from the guidelines, taking into account individual circumstances, may be appropriate.
These guidelines do not address all elements of standard practice and accepts that individual clinicians are
responsible for:
• providing care within the context of locally available resources, expertise, and scope of practice.
• supporting patient rights and informed decision making, including the right to decline intervention or
ongoing management.
• advising patients of their choices in an environment that is culturally appropriate and which enables
comfortable and confidential discussion. This includes the use of interpreter services where
necessary.
• ensuring informed consent is obtained prior to delivering care.
• meeting all legislative requirements and professional standards.
• applying standard precautions, and additional precautions as necessary, when delivering care; and
• documenting all care in accordance with mandatory and local requirements.
6
PRINT WARNING – Content is continually being revised. ALWAYS refer to the electronic copy for the latest version. Users must ensure that any printed copies of this document are of the latest version.
This guideline has been developed for WA Health practice setting only. Clinical content is intended to guide clinical practice and does not replace clinical judgement. Modification will occur according to
internal audit processes and literature review. The rationale for the variation from the guideline must be documented in the clinical record.
Recommended citation:
Department of Health WA Abortion Care Clinical Guidelines. © State of Queensland (Queensland
Health) 2024

This work is licensed under a Creative Commons Attribution-Non-Commercial-No Derivatives V4.0

International licence. You are free to copy and communicate the work in its current form for non-
commercial purposes, as long as you attribute Queensland Clinical Guideline, Queensland Health and
abide by the licence terms. You may not alter or adapt the work in any way. To view a copy of this
licence, visit creativecommons.org/licenses/by-nc-nd/4.0/deed.en

Heath Network Directorate and Clinical Excellence Division acknowledges and thanks Queensland
Health for developing and providing this evidence based clinical guideline, which Heath Network
Directorate and Clinical Excellence Division have adapted for the Western Australian legislation, context,
and people. For further information, contact Queensland Clinical Guideline, RBWH Post Office, Herston
Qld 4029, email [email protected]. For permissions beyond the scope of this license,
contact: Intellectual Property Officer Queensland Health, GPO Box 48, Brisbane Qld 4001, email
[email protected].

Contact:
Email: [email protected]
Website: health.wa.gov.au/abortion

7
PRINT WARNING – Content is continually being revised. ALWAYS refer to the electronic copy for the latest version. Users must ensure that any printed copies of this document are of the latest version.
This guideline has been developed for WA Health practice setting only. Clinical content is intended to guide clinical practice and does not replace clinical judgement. Modification will occur according to
internal audit processes and literature review. The rationale for the variation from the guideline must be documented in the clinical record.
Summary of Abortion Healthcare under the Public Health Act 2016 (the Act)

8
PRINT WARNING – Content is continually being revised. ALWAYS refer to the electronic copy for the latest version. Users must ensure that any printed copies of this document are of the latest version.
This guideline has been developed for WA Health practice setting only. Clinical content is intended to guide clinical practice and does not replace clinical judgement. Modification will occur according to
internal audit processes and literature review. The rationale for the variation from the guideline must be documented in the clinical record.
Medical Abortion with MS – 2 Step

9
PRINT WARNING – Content is continually being revised. ALWAYS refer to the electronic copy for the latest version. Users must ensure that any printed copies of this document are of the latest version.
This guideline has been developed for WA Health practice setting only. Clinical content is intended to guide clinical practice and does not replace clinical judgement. Modification will occur according to
internal audit processes and literature review. The rationale for the variation from the guideline must be documented in the clinical record.
Section 1: Western Australian Law
1.1 Performing an abortion
Table 1. Performing an abortion
Aspect Definition
Performance of an abortion is defined in the Act 3 as follows:
A person performs an abortion on another person (patient) if the person does any
act with the intention of causing the termination of a pregnancy of the other
person.
Context The acts to which this applies includes the following:
• Prescribing an abortion drug for another person (patient).
• Supplying an abortion drug to another person.
• Administering an abortion drug to the other person.
• Carrying out a surgical or other procedure on the other person.

Expert clinical recommendation is that performing an abortion commences when

the therapeutic intervention of abortion starts and includes:
• Prescribing an abortion drug
• Dispensing, supplying, or administering an abortion drug on a medical
practitioner’s and/or prescribing practitioners’ instruction.
Healthcare
• Feticide or a surgical procedure of abortion performed by a medical
included in
practitioner.
performing an
abortion • Feticide or a surgical procedure of abortion assisted by an authorised or
student healthcare practitioner [refer to Table 3. Assisting with an abortion].
All health professionals, including community pharmacist’s, must provide adequate
pharmaceutical information to the patient and/or their support person to ensure the
safe and effective use of the drugs in a manner that protects the patient’s privacy.

Expert clinical recommendation is that performing an abortion does not include

clinical care provided before or after performing an abortion including, for example:
Healthcare not • Clinical assessment, pre-operative preparation, referral, or non-directive
included in counselling, intrapartum or postpartum care after feticide or after administration
performing an of an abortion drug.
abortion • Refer to Table 17. Clinical assessment prior to abortion; and
• Refer to Table 38. Post-abortion care considerations.

10
PRINT WARNING – Content is continually being revised. ALWAYS refer to the electronic copy for the latest version. Users must ensure that any printed copies of this document are of the latest version.
This guideline has been developed for WA Health practice setting only. Clinical content is intended to guide clinical practice and does not replace clinical judgement. Modification will occur according to
internal audit processes and literature review. The rationale for the variation from the guideline must be documented in the clinical record.
1.2 Registered healthcare practitioner responsibilities
The legal responsibilities for the registered healthcare practitioner in relation to performing an abortion, are
specified according to the gestational age of the pregnancy.
4

Table 2. Registered health practitioner responsibilities

Aspect Lawful action

The Department of Health considers that:
• ‘Not more than 23 weeks’ means less than or equal to 23+0 weeks.
Context • ‘More than 23 weeks’ means at or after 23+1 weeks.
Use clinical judgement when determining gestational age in individual
circumstances
Medical or Surgical Abortions:
A medical practitioner is authorised to perform an abortion on a person (patient)
who is not more than 23 weeks pregnant.
A prescribing practitioner (Endorsed Midwives, Nurse Practitioners, Medical
Practitioners, meaning a person who is authorised under the Medicines and
Poisons Act (2014) 5 to prescribe an abortion drug) is authorised to perform a
medical abortion on a person (patient) who is not more than 23 weeks pregnant if
the prescribing practitioner performs the abortion by:
• Prescribing an abortion drug for the person (patient); or
• Supplying or administering an abortion drug to the person (patient).
A registered health practitioner in a relevant health profession (other than
Less than or pharmacy) is authorised to perform a medical abortion on a person (no more than
equal to 23+0 23 weeks gestation) by supplying or administering an abortion drug to the person if
weeks the registered health practitioner, in accordance with the Medicines and Poisons Act
gestation (2014) 6, supplies or administers the abortion drug to the person on the direction of a
medical practitioner or prescribing practitioner.
Medical Abortion:
A pharmacist is authorised to perform an abortion on a person by supplying an
abortion drug to the person if the pharmacist, in accordance with the Medicines
and Poisons Act (2014) 7:
• dispenses the abortion drug to the person under a prescription issued by a
medical practitioner or prescribing practitioner; or
• otherwise supplies the abortion drug to the person on the direction of a
medical practitioner or prescribing practitioner.

A medical practitioner may perform an abortion on a person who is equal or greater

than 23+1 weeks pregnant after consulting with another medical practitioner who
has also assessed the person and both medical practitioners consider the abortion
Equal or is appropriate in all the circumstances having regard to 8:
greater than
23+1 weeks • All relevant medical circumstances; and
gestation • The person's current and future physical, psychological, and social
circumstances; and
• Professional standards and guidelines.

11
PRINT WARNING – Content is continually being revised. ALWAYS refer to the electronic copy for the latest version. Users must ensure that any printed copies of this document are of the latest version.
This guideline has been developed for WA Health practice setting only. Clinical content is intended to guide clinical practice and does not replace clinical judgement. Modification will occur according to
internal audit processes and literature review. The rationale for the variation from the guideline must be documented in the clinical record.
Aspect Lawful action

A registered health practitioner in a relevant health profession (other than

pharmacy) is authorised to perform a medical abortion on a person (at or after 23+1
weeks gestation) by supplying or administering an abortion drug to the person if the
registered health practitioner, in accordance with the Medicines and Poisons Act
(2014) 9, supplies or administers the abortion drug to the person on the direction of a
medical practitioner.
A pharmacist is authorised to perform an abortion on a person by supplying an
abortion drug to the person if the pharmacist, in accordance with the Medicines
and Poisons Act (2014) 10:
• dispenses the abortion drug to the person under a prescription issued by a
medical practitioner; or
• otherwise supplies the abortion drug to the person on the direction of a
medical practitioner.

1.3 Assisting by a registered health practitioner or student

A registered health practitioner in a relevant health profession, acting in the course of the practice of that
profession, may assist in the performance of an abortion. A student in a relevant health profession may also
assist.
Table 3. Assisting with an abortion

Aspect Lawful action

A registered health practitioner means a person registered under the Health
Registered health Practitioner Regulation National Law (Western Australia) 11 to practice a health
practitioners profession (other than as a student).

A relevant health profession means any of the following health professions:

• Aboriginal and Torres Strait Islander health practitioner.
• Medical.
Relevant health
• Midwifery.
profession
• Nursing; or
• Pharmacy.

Student health practitioners are permitted to assist in the performance of an abortion

to the extent necessary to complete the student’s program of study under
supervision of:
Student health • A medical practitioner or prescribing practitioner performing the abortion; or
practitioner • An authorised health practitioner lawfully assisting in the performance of
an abortion; or
• The student’s primary clinical supervisor.

12
PRINT WARNING – Content is continually being revised. ALWAYS refer to the electronic copy for the latest version. Users must ensure that any printed copies of this document are of the latest version.
This guideline has been developed for WA Health practice setting only. Clinical content is intended to guide clinical practice and does not replace clinical judgement. Modification will occur according to
internal audit processes and literature review. The rationale for the variation from the guideline must be documented in the clinical record.
1.4 Conscientious objection
Refer to Definition of terms and Table 1 Performing an abortion.

Table 4. Conscientious objection

Aspect Lawful action
Registered health practitioners and those they direct, including medical
practitioners, Aboriginal and Torres Strait Islander health practitioners, midwives,
nurses, pharmacists, and students who have a conscientious objection to the
performance of an abortion and who are asked by the authorised health
practitioner to 12:
Relevant to
• Perform or assist with the performance of an abortion.
• Decide whether an abortion should be performed; or
• Advise a person about the performance of abortion on a patient.

When a registered health practitioner has been requested by a patient for

information on abortion or has been asked to participate in an abortion and has a
Disclosure of
conscientious objection to abortion, the practitioner must disclose their
objection
conscientious objection to the patient immediately

A medical practitioner or prescribing practitioner (nurse practitioner or endorsed

midwife) who will not participate in an abortion for any reason (including
conscientious objection) must, without delay, refer the patient to a health
Referral or practitioner or health facility which they believe can provide the requested
transfer of care service(s); or give the patient information that has been approved by the Chief
Health Officer, about how the requested services can be accessed

Registered health practitioners who conscientiously object to assisting in an

abortion must notify the practitioner requesting their assistance of their objection
at the time the assistance request is made.
Assisting in an A student who conscientiously objects to assisting in an abortion should notify the
abortion person supervising them of their objection at the time the supervisor makes the
request. A student has a right to not participate in an abortion, and this right must
be respected by their supervisor.

Despite any conscientious objection in relation to abortions, a medical practitioner

is under a duty to perform an abortion in an emergency where the abortion is
Duty to perform necessary to preserve the life of the patient.
or assist when
necessary to Despite any conscientious objection in relation to abortion, registered health
save life practitioner is under a duty to assist in an emergency where an abortion is
necessary to preserve the life of the patient.

The conscientious objection provision does not extend to:

Care that is not a
matter for • Administrative, managerial, or other tasks ancillary to the performance of
conscientious the abortion.
objection Refer to Table 1 Performance of an abortion.

Practitioners In an emergency, a registered health practitioner is under a duty to assist a medical

practitioner performing an abortion in the circumstances outlined above
14
assisting
Despite any conscientious objection in relation to abortions, a medical practitioner,
is under a duty to perform an abortion in an emergency where the abortion is
Conscientious necessary to preserve the life of the patient.
objectors Despite any conscientious objection in relation to abortion, a registered health
practitioner is under a duty to assist a medical practitioner in an emergency where
an abortion is necessary to preserve the life of the patient.

1.6 Safe access zones

The purpose of safe access zones is to protect the safety and well-being and respect the privacy and
dignity of patients and other persons accessing premises where performance of an abortion occurs 15.
Table 6. Safe access zone
Aspect Lawful action
Premises for performing abortions means premises where either or both of the
following take place:
Premises for • Abortions are performed by registered health practitioners.
performing
abortions • Registered health practitioners assist in the performance of abortions; but
• Does not include a pharmacy.

Safe access zone means the area:

Safe access zone • Within the boundary of premises for performing abortions; and
• Within 150 metres outside the boundary.
Prohibited conduct means:
• Harassing, hindering, intimidating, interfering with, threatening, or obstructing a
person, including by recording the person by any means without the person's
consent and without a reasonable excuse, which may result in deterring the
person from:
o Entering or leaving premises for performing abortion; or
Prohibited conduct
o Performing, or receiving, an abortion at premises for performing
abortions.
And an act that could be seen or heard by a person in the vicinity of premises for
performing abortions, that may result in deterring the person or another person from:
• Entering or leaving the premises; or
• Performing an abortion or receiving an abortion at the premises.
PRINT WARNING – Content is continually being revised. ALWAYS refer to the electronic copy for the latest version. Users must ensure that any printed copies of this document are of the latest version. 14
This guideline has been developed for WA Health practice setting only. Clinical content is intended to guide clinical practice and does not replace clinical judgement. Modification will occur according to
internal audit processes and literature review. The rationale for the variation from the guideline must be documented in the clinical record.
1.7 Non-compliance with the Act
Table 7. Non-compliance
Aspect Lawful action
Performance of an abortion:
Abortion is considered a health procedure and should be conducted by a registered
health practitioner.
An unqualified person must not perform an abortion, as this is a crime attracting a
prison term.
Prohibited behaviour in a safe access zone:

Offences A person commits an offence if:

• The person intentionally engages in prohibited conduct.
• The prohibited conduct occurs in a safe access zone and the person is reckless
in relation to that circumstance.

Maximum penalty for prohibited behavior in a Safe Access Zone is

imprisonment for one year and a fine of $12 000.

Non-compliance with relevant registration and accreditation standards, professional

standards (including codes of ethics, codes of conduct and competency standards),
policies and guidelines is subject to the same professional and legal
consequences as for all other healthcare.

As for other healthcare, the following may also apply:

Professional
• Professional and legal consequences for non-compliance with the Act, including
conduct
mechanisms available under the Health Practitioner Regulation National Law (WA)
Act 2010 16 and the Health and Disability Services (Complaints) Act 199517.
• Laws for duty of care, reasonable skill, and care.
• Civil or criminal responsibility for harm that results from a failure to act with
reasonable skill and care.

Aspect Considerations
• Patients requesting an abortion require assessment by a registered health
practitioner who is not a conscientious objector.
• Refer to Table 4. Conscientious objection.
• Where abortion healthcare is not locally available, support patients to access
the service, as for any other healthcare not locally available.
• Provide care to patients and families that acknowledges and respects
their cultural beliefs and practices. (See Appendix B and Appendix C for
cultural considerations statements.)
• If required, access and provide appropriate interpreter services.
Access to
abortion • Provide documented information to consumers, external service providers,
healthcare support agencies and other Health Service Providers (HSP) on the choices
available within the service, and on routes of access to these services.
• Facilitate access (including via patient travel subsidy scheme, when required)
as early as possible and without delay to:
o Reduce the likelihood of associated health risks; and
o Support the patient in their preference for an abortion procedure that may
be impacted by gestational age limitations.
• The patient accessing an abortion (and an escort) may be eligible for PATS if
they do not have access to safe, private accommodation 18.

• Document referral pathways within and between HSP’s (e.g. between

departments within a facility, between facilities, and between a facility and
external agencies or General Practitioners (GP)).
• Consider engagement with Statewide external service providers and
agencies in the development of referral pathways and mechanisms.
• Provide documented referral pathways to external service providers,
agencies, and GPs.
Referral • Inform healthcare professionals in contact with patients seeking abortion (e.g.
emergency departments, GPs) about referral pathways.
• If there is a conscientious objection to the performance of an abortion, act in
accordance with Table 4. Conscientious objection.
• Where the patient considers but does not proceed to abortion, provide
information and access to appropriate referral pathways (e.g. access to a
social worker, referral for antenatal care, cultural support).

The most appropriate care setting for abortion is dependent on the:

• Method of abortion chosen.
• Gestation of the pregnancy.
• Preferences of the patient and their care provider.
• The service capabilities of the facility; and
• For early Medical Abortion [refer Section 7 Medical Abortion]
o Access to working phone and reliable transport. Consider road
access and weather conditions.
Care setting
o Access to safe and private accommodation, including bathroom
facilities and a support person.
o Make a risk assessment of the patient’s ability to accurately follow
instructions for taking medication; and their access to appropriate care in the
unlikely event of a medical emergency; and
o Ensure there are local arrangements for the safe and sensitive handling,
storage, and management of fetal tissue (if required), including individual
and cultural requirements.

• Cultural respect is achieved when the health system is a safe environment

for West Australians who identify as Aboriginal or from a Culturally and
Linguistically Diverse community, and where cultural differences are
respected.
• The experiences of Aboriginal health care users, including having their
cultural identity respected, is critical for assessing cultural safety. Aspects of
Cultural
cultural safety include good communication, respectful treatment,
considerations
empowerment in decision making and the inclusion of family members 19.
• See Appendix B for the Aboriginal Cultural Considerations Statement.
• See Appendix C for the Culturally and Linguistically Diverse Considerations
Statement.

Aspect Considerations
• For healthcare professionals involved in the provision of abortion healthcare,
provide:
Healthcare
professionals o Ongoing training and education 20.
o Access to non-judgemental counselling and debriefing support.

• Support access to information on:

o Western Australian Law and the Public Health Act 2016 21:
o Conscientious objection rights and responsibilities.
o Contemporary approach to abortion healthcare provision.
o Sensitive communication and confidentiality.
Student health
practitioners o Cultural considerations.
o Other matters relevant to the clinical placement.
• If the student health practitioner holds a conscientious objection, support:
o Alternative clinical learning.
o Access to non-judgemental counselling and debriefing support (if required).

Includes for example, privacy, consent, decision making, sensitive

communication, medication administration, staff education and support and
Standard care
culturally appropriate care.

PRINT WARNING – Content is continually being revised. ALWAYS refer to the electronic copy for the latest version. Users must ensure that any printed copies of this document are of the latest version. 18
This guideline has been developed for WA Health practice setting only. Clinical content is intended to guide clinical practice and does not replace clinical judgement. Modification will occur according to
internal audit processes and literature review. The rationale for the variation from the guideline must be documented in the clinical record.
Section 3 Individual case considerations
Abortion healthcare is provided in partnership with the patient (and family, where appropriate) and the
healthcare professional. It is led by the person's health needs, concerns and choices. Use clinical judgement
when determining if all aspects of care are appropriate for the individual. Consider cultural aspects and
minimising harm to the individual, family, and community.
Health practitioners providing abortion healthcare can access the Royal Australian and New Zealand College
of Obstetricians and Gynaecologists (RANZCOG), Clinical Guideline for Abortion Care (2023) 22 which
provides evidence-based recommendations to healthcare practitioners who provide advice and abortion care
in Australia and Aotearoa New Zealand.
Health practitioners providing abortion healthcare are also advised to familiarise themselves with their legal
responsibilities under the Act 23.
3.1 Consent
See Consent to Treatment Policy (health.wa.gov.au)- WA Policy 24
Table 10. Consent

Aspect Considerations
Where a patient is seeking to abort a pregnancy, it is necessary to obtain written
informed consent to the type of procedure recommended and selected. Consent
procedures should be followed.
To achieve this requires provision of suitable levels of information the patient
needs to be able to weigh up all the factors relevant to them and the risks
involved. If more than one step, or procedure, is involved then it is important to
ensure the person is giving consent to each step or procedure.
WA health practitioners must follow usual consent processes as set out in the WA
Health Consent to Treatment Policy including:
Consent • Assessment of capacity.
• Discussion of available methods of abortion.
• Risks and complications of each method of abortion.
• Access to a working phone, transport, road access, bathroom facilities
and supports (for early medical abortion not completed in hospital).
• Risk assess patient access to appropriate care in the unlikely event of a
medical emergency; and
• The right of the patient to choose where to receive treatment.

Persons over the age of 18 are presumed to have full lawful capacity to consent to
medical treatment unless there is sufficient evidence to the contrary (Sec 43(1(a)) of
the Guardianship and Administration Act 1990) 25.

Capacity to Capacity to consent is usually evidenced by the person’s demonstration of a

consent sufficient understanding of their condition, the treatment options available
(including the benefits and effect of treatment options), the consequences of the
condition and those of having, or not having any treatment, and the risks
associated with each treatment.

Therefore, where a patient does not have the capacity to make reasonable
judgments about abortion treatment and care, the relevant parties can apply to
the SAT to make a decision on their behalf.

Where the patient is deemed to not have capacity and has a Guardian appointed
under the Guardianship and Administration Act 1990, an application to SAT is
Adults who lack still required. The Guardian cannot make the decision regarding the abortion on
capacity the patient’s behalf.

Abortion of a pregnancy of an adult who lacks capacity is a complex case and it

is strongly recommended the health practitioner seek legal advice.

In an emergency situation, where urgent treatment is required, and it is not

practical for the health professional to obtain a decision of the SAT in respect to
the performance of an abortion; an abortion may be performed to:
• save the patient’s life.
• prevent serious damage to the patient’s health; or
• to save another fetus.
But does not include psychiatric treatment, or sterilization of the patient as per
S110ZH(b) of the Guardianship and Administration Act 1990.

A young person is considered a mature minor when they demonstrate sufficient

maturity and intelligence to enable them to understand fully what medical
treatment is propose. 28, 29
• A mature minor can consent to medical procedures, in the same way as an
autonomous adult with capacity.
• The decision about whether a young person is a mature minor is a matter for
the treating practitioner.
• Consider additional elements of informed consent when obtaining consent
Young person who from a young person who is a mature minor (e.g. the ability to freely and
is assessed as a voluntarily make decisions without coercion).
mature minor 27 • It is recommended that legal advice is sought if there is any doubt about
the capacity of a young pregnant person to consent to the proposed
treatment where no other person is representing them or presenting orders
permitting the proposed treatment.

The law requires that when a young person assessed as a mature minor
chooses not to include their parents/guardians in consultation, this must be
respected, and confidentiality not breached.
• Involve appropriately skilled healthcare professionals for assessments of
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This guideline has been developed for WA Health practice setting only. Clinical content is intended to guide clinical practice and does not replace clinical judgement. Modification will occur according to
internal audit processes and literature review. The rationale for the variation from the guideline must be documented in the clinical record.
Aspect Considerations
competency, psychosocial assessments and family court matters where
clinically indicated.
For more information and further factors to consider when assessing the maturity
of a minor see WA Country Health Service Working with Youth: A legal resource
for community-based health professionals
(https://www.wacountry.health.wa.gov.au/~/media/WACHS/Documents/About-
us/Publications/Working_with_Youth_-_WA_Health.PDF).

• For a young person/patient under the age of 18 who lacks capacity to make
decisions about their day-to-day life or general medical treatment, it is
necessary to consider seeking the consent of the pregnant person’s
parent(s) or guardian before undertaking the proposed treatment, if the
pregnant person agrees to the involvement of the parent or guardian in the
decision-making process 30.
• If the young person agrees to involve a parent or guardian, the parent or
guardian may consent or refuse consent to the performance of the abortion
on the patient.
• If the minor does not wish for parent/legal guardian involvement or the registered
health practitioner is of the view that the parent or legal guardian is not acting in
Young person the best interests of the child, the registered health practitioner can apply to the
who is not a Supreme Court or the Family Court of WA to determine the course of action for
mature minor the young person.
• The young person can access free legal assistance through Legal Aid WA and
information should be given to the young person regarding this assistance.
• Where another person is seeking the treatment on behalf of a young pregnant
person who apparently lacks capacity to give consent, the lawful basis upon
which that person purports to represent the young pregnant person will be
verified before proceeding with any treatment.
• It is a matter for the treating physician to be reasonably satisfied that the
person has authority to seek the treatment on behalf of the young person.
• Legal advice should be sought in circumstances where legal authority is
in question or authority of a court or tribunal is required for abortion.

Aspect Consideration
A young person should not be presumed to lack capacity to consent to medical
treatment by virtue of their age. In the majority of cases, a young pregnant person
under the age of 14 years would require a parent or person having parental
Young person authority to provide consent to treatment. However, there may be circumstances
less than 14 where a person under 14 years is deemed to be a mature minor.
years Mandatory reporting requirements for sexual offences and suspected sexual abuse
apply, irrespective of the treatment sought. The health practitioner should consider
these requirements carefully 31. See Table 12 Suspicion of Abuse.

3.3 Suspicion of child harm and exploitation

Table 12. Suspicion of abuse
Aspect Consideration
Mandatory reporting requirements apply where a child has been, or is likely to
be, the victim of a sexual abuse, irrespective of the treatment sought.
Section 124(B) of the Children and Community Services Act 2004 33 places an
obligation on certain people in WA, including doctors, nurses, and midwives, to
report cases of child sexual abuse to the Department of Communities Mandatory
Reporting Service.
A child is a person less than 18 years of age, or who appears to be less than 18
years of age if the person’s age cannot be proved 34.
Section 124(A) of the Children and Community Services Act 2004, defines
sexual abuse in relation to a child, as including sexual behavior in circumstances
where:
• the child is subject to bribery, coercion, a threat, exploitation, or violence; or
Suspicion of
harm
32 • The child has less power than another person involved in the behaviour; or
• There is significant disparity in the developmental function or maturity of the
child and another person involved in the behaviour.
• A mandatory report must be made as soon as reasonably practicable to the
Department of Communities after the reporter forms their belief regarding
the sexual abuse of the child. The Mandatory Reporting Service can be
contacted 24 hours a day 7 days a week by phone on 1800 708 704 35 to:
I. report immediate concerns for the safety of a child
II. discuss with a specialist in child protection any grounds on which you
have formed a belief that a child has been or is currently being
sexually abused
III. seek advice on reporting procedures.

• The health practitioner must, if they form a reasonable belief that a child
has been, or is at risk of harm, exploitation, or sexual abuse, report their
belief to the Department of Communities.
• If a child is at imminent risk of harm or exploitation, call police immediately on
000.
• It is important the health practitioner does not conduct their own
investigations or test any allegations at all. The mandatory reporting
Reporting
requirement extends only to reporting a reasonable belief and the
requirements
36

basis of that belief.

• For additional information and guidance on Mandatory Reporting, child harm or
exploitation and domestic and family violence see Department of Communities
(wa.gov.au)or the Department of Communities Mandatory Reporting Guide:
Western Australia May 2024 (https://www.wa.gov.au/system/files/2024-
05/mandatory_reporting_guide_western_australia.pdf).

3.4 Sexual Assault, Family, Domestic and Intimate Partner Violence and Reproductive Coercion
Table 13. Special circumstances
Aspect Consideration
• If the pregnancy is reported to have resulted from forced sexual activity, or
domestic and family violence (or fear of violence) is disclosed, sensitively
discuss options for:
o Social work support.
o Relocating, if in continued danger.
o Routine sexual health checks and treatment as required, and.
o A medical examination and documentation of findings.
• Provide abortion healthcare on the basis of the patient’s request 37.
• Ask the patient if they would like a referral to sexual assault counselling. This
can be done through the Sexual Assault Resource Centre (SARC), Family
Services or Sexual Health Quarters.
• Contact SARC duty officer on (08) 6458 1820 for more individualised advice.
Sexual assault • Ask the patient if they would like police involvement. Note that products of
conception can be used as DNA evidence, and this can be requested by
police and taken as evidence.
• It is possible that the patient is at ongoing risk of harm. Follow the Statewide-
Maternity-Shared-Care-Guidelines
(https://kemh.health.wa.gov.au/~/media/HSPs/NMHS/Hospitals/WNHS/Docu
ments/Clinical-guidelines/Statewide-Maternity-Shared-Care-Guidelines.pdf) to
screen for FDV and complete the appropriate risk assessment.
• See Appendix D FDV Pathway
• For more information, see the Sexual Assault Resource Centre
• Support the person’s choices for ongoing healthcare and involvement.
• Following an abortion, Police may submit a written request for fetal tissue – cord

Family, domestic, and sexual violence is the use of a range of tactics by an abuser to
create vulnerabilities, and to achieve power over a partner through coercive control.
This includes physical violence or other forms of violence including emotional and
psychological abuse.

Reproductive coercion is behaviour that interferes with the autonomy of a person to

make decisions about their reproductive health. It includes any behaviour that has
the intention of controlling or constraining another person’s reproductive health
decision-making, for example:

• Controlling or sabotage of another person’s contraception.

• Pressuring another person into pregnancy
• Controlling the outcome of another person’s pregnancy, e.g. forcing someone
towards abortion, adoption, care, kinship care or parenting.
• Forcing or coercing a person into sterilisation, including tubal ligation,
vasectomy, and hysterectomy.

It is important to be aware that people seeking an abortion might have been

exposed to reproductive coercion or family, domestic or sexual violence.
If suspected or disclosed, please see Department of Communities Family and
Family, domestic, Domestic Violence Services and Resources (www.wa.gov.au) for information on
or intimate partner support services.
violence and
reproductive Advice can also be sought from the Women’s Domestic Violence Helpline or the
coercion KEMH Women’s Health Strategy and Programs Family and Domestic Violence
Toolbox provides information on intimate partner violence and resources.

Sexual Health Quarters Safe to Tell webpage has a number of resources, e-learning
for clinicians and contact and referral information for patients experiencing
reproductive coercion and/or intimate partner violence. Safe to Tell - Sexual Health
Quarters (shq.org.au)

The Royal Australian College of General Practitioners has clinical resources and
training on identifying and responding to intimate partner violence RACGP - Intimate
partner abuse and violence: Identification and initial response

Additional training and resources for reproductive coercion and intimate partner
violence include:

Reproductive abuse | 1800RESPECT

DV Alert Training:
https://www.dvalert.org.au/workshops-courses/elearning-workshops/elearning

Aspect Consideration
• If FGC/M is identified, refer to Female Genital Cutting/Mutilation
Clinical Practice Guideline Female Genital Mutilation
(https://www.kemh.health.wa.gov.au/~/media/HSPs/NMHS/Hospital
s/WNHS/Documents/Clinical-guidelines/Obs-Gyn-
Female genital Guidelines/Female-Genital-Mutilation-FGM.pdf?thn=0 0). Use
cutting/ clinical judgement and individually assess the clinical and
mutilation psychological circumstances of each patient.
(FGC/M)
• Refer any patient who has been identified with FGC/M to Social
Work to discuss Australian legal requirements.
• If deinfibulation indicated, seek specialist advice.

3.6 Documentation of decisions

Table 16. Documentation
Aspect Consideration
The authorised medical practitioner and other health practitioners are required to
keep accurate health care records concerning the care and treatment of the patient.
Documentation should include:
• An assessment of the pregnancy.
• A detailed and well documented informed decision-making process and informed
consent.
Less than or • Clinical process to determine successful completion of abortion.
equal to 23 • Details of follow up appointments.
weeks
• Location of the abortion.
• Details of discussion of and provision of contraception; and
• Completion of a 'Notification of abortion (termination of pregnancy) E-form
(available at: https://www.health.wa.gov.au/Articles/A_E/Abortion)

Both medical practitioners together with a social worker, document:

• A complete socioecological assessment of the patient and pregnancy.
• Clinical opinion relevant to the patient’s medical circumstances and their
current and future physical, psychological, and social circumstances and the
At or after 23 relevant professional standards followed.
weeks • Details of the second medical practitioner who assessed the patient.
and/or
complex • A detailed and well documented informed decision-making process and informed
case consent.
• Clinical process to determine successful completion of abortion.
• Details of follow up appointments.
• Location of abortion
• Details of discussion of and provision of contraception; and
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This guideline has been developed for WA Health practice setting only. Clinical content is intended to guide clinical practice and does not replace clinical judgement. Modification will occur according to
internal audit processes and literature review. The rationale for the variation from the guideline must be documented in the clinical record.
• Completion of a 'Notification of abortion (termination of pregnancy) E-form
(available at: https://www.health.wa.gov.au/Articles/A_E/Abortion

3.7 Suspected fetal abnormality

Table 17. Suspected fetal abnormality
Aspect Consideration
• If fetal abnormality suspected, discuss with the patient:
o Chromosomal analysis.
Suspected o Histopathology; and
fetal o Fetal autopsy.
abnormality • Consider referral to Genetic Health WA and/or Maternal Fetal Medicine service at
nearest available local health service.

Aspect Consideration
Discuss request for abortion care in a non-judgemental and supportive manner:
• Obtain medical, gynaecological, obstetric, and sexual health history 38, 39
including date of last menstrual period.
Review history
• Obtain psycho-social history 40, 41 including mental health issues, screening
for family and domestic violence (FDV), reproductive coercion and comply
with mandatory reporting requirements.

• Confirm gestational age and location of pregnancy 42.

• Undertake a physical exam as indicated by the history and signs and
symptoms including:
Clinical exam and o Observations 43, 44 and body mass index (BMI).
investigations • Undertake routine testing (if not already screened) as indicated for
the gestational age including as required for:
o Haemoglobin, blood group and Rh status to identify Rh negative
patients requiring Rh D immunoglobulin 45, 46

• An USS is recommended prior to abortion up to 14 weeks gestation if there is

uncertainty about gestational age by clinical means, or if there are symptoms or
signs suspicious for ectopic pregnancy or other clinical concerns.
• Where gestational age has been established by clinical means, the decision
about USS prior to abortion should be made according to patient preferences
Ultrasound scan
and access to services.
(USS)
• After 14 weeks pregnant, all patients seeking an abortion should have an USS to
confirm gestational age and position of placenta if previous uterine surgery.
• Consider the persons age, context, and individual circumstances. Inform the
patient that USS images and audio will not be shown to them unless
requested.

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This guideline has been developed for WA Health practice setting only. Clinical content is intended to guide clinical practice and does not replace clinical judgement. Modification will occur according to
internal audit processes and literature review. The rationale for the variation from the guideline must be documented in the clinical record.
Aspect Consideration
• Unintended pregnancy is a sexually transmitted infection(s) (STI) risk.
Perform a sexual health check and assess other STI risks including:
o Condom use.
o History of STI.
o Symptoms (e.g. discharge, pain on urination, genital rashes).
• Noting many STIs are asymptomatic in females and people with vaginas e.g.
Sexual health chlamydia and gonorrhoea, so if high suspicion of STI it is advised to treat on
check the day of assessment.
• Gain consent for STI screening as per Department of Health Silver Book
guidelines, including syphilis serology Quick guide to STI testing
(health.wa.gov.au) 47.
• Refer also to STI Guidelines Australia STI Guidelines Australia | Australian STI
Guidelines website 48 (sti.guidelines.org.au)..

• Facilitate timely referral and coordination with other facilities, disciplines, or

49
agencies as required, for:
o Specialist medical assessment (e.g. cardiologist, clinical genetics
services, tertiary imaging).
o Psychosocial counselling/support:
Pre-abortion
 Especially where risk factors are identified (e.g. young person, people
referral
with physical or intellectual disabilities, mental illness (past or current),
coordination
rape or sexual assault, domestic violence (including sexual violence),
fertility issues and religious or cultural beliefs/values).
o Mental health support/treatment 50.
• Abortion procedure.

• Discuss contraceptive options at the time of initial consultation, abortion

procedure or immediately after 51, 52.
• Provide patient information on contraception options Contraceptives-methods-
poster
Contraception (https://kemh.health.wa.gov.au/~/media/HSPs/NMHS/Hospitals/WNHS/Documen
ts/Patients-resources/Contraceptives-methods-poster.pdf)
• Refer to Table 39. Contraception provision.

• Consider additional health screening or advice including:

o Cervical screening test.
Additional o appropriate for support for any drug and alcohol issues; and
healthcare o Screening for Family Domestic Violence (FDV) or reproductive coercion (see
Table 13.

4.1 Psychological support

The decision to abort a pregnancy may be a difficult and sometimes distressing process 56. Consider the
person’s psychological, spiritual, and cultural beliefs when providing abortion care. The patient may be clear
in their decision, require supportive listening or further psychological support.
Table 19. Information and counselling

Aspect Consideration
Support the decision-making process by providing accurate, impartial, and easy to
understand information including:
• Options to continue the pregnancy and parent the child or adoption for the
child. Pregnant and considering adoption for your child (wa.gov.au)
• Documentation of discussions regarding all options for abortion including
public and private facility options and abortion methods based on individual
needs and circumstances.
Information • Post-abortion considerations (e.g. contraceptive options and non-
judgemental unintended pregnancy counselling support).
• Information about local support groups relevant to the circumstances
• Birth registration requirements 57 [refer to Table 24 Birth registration].
Refer to RANZCOG Decision Aid to support the decision-making discussion
Abortion-Decision-Aid.pdf (ranzcog.edu.au) 58

There is no mandatory counselling requirement prior to obtaining patient’s consent

to the abortion.
The support needs of every person considering abortion of pregnancy will be
different. For most, and particularly those accessing early medical abortion, the
decision is made early, negative consequences are minimal and there is little
disruption to their ongoing lives 59. However, it may be helpful for patients to
access non-judgemental and unbiased counselling both pre and post abortion.
Counselling Unplanned pregnancy counselling services offer independent and non-
judgemental counselling to assist with decision making and post-abortion
counselling. These services are free and optional.
A list of services is available on the WNHS website with contracts to provide non-
judgemental supportive counselling with respect to consideration of pregnancy
options and unplanned pregnancy.
King Edward Memorial Hospital - Abortion counselling and support
(https://www.kemh.health.wa.gov.au/Pregnancy-and-Birth/Abortion/Abortion-
counselling)
PRINT WARNING – Content is continually being revised. ALWAYS refer to the electronic copy for the latest version. Users must ensure that any printed copies of this document are of the latest version. 29
This guideline has been developed for WA Health practice setting only. Clinical content is intended to guide clinical practice and does not replace clinical judgement. Modification will occur according to
internal audit processes and literature review. The rationale for the variation from the guideline must be documented in the clinical record.
Aspect Consideration
Appropriate communication is an important aspect of abortion care, be sure to:
• Allow space to identify if the patient has alternate gender identity.
• Use respectful language when referring to the pregnancy.
• Refer to the possible father or attending male as ‘partner in pregnancy,’ unless the
person refers otherwise.
• Give time for questions to be asked and answered.
• Answer questions honestly and respectfully.
• Use straightforward and simple language.
• Acknowledge and reassure that it is normal to feel a range of emotions (e.g.
grief, sadness, relief); and
Communication
• Involve the multi-disciplinary team if required.

DO NOT:
• Refer to the pregnancy as ‘products of conception’ or ‘it.’
• Refer to the pregnancy as a ‘baby’ (unless the person does).
• Apply judgement for individual motives or reason for abortion.
• Imply fault or blame about contraception use/lack of use; or
• Try to persuade the patient to change their mind.

If appropriate, discuss with the patient (and if they choose their family and/or other
children) options for ‘memory creation’ which may include:
• Photographs.
• Hand/footprints.
Memory creation
• Holding or bathing; and/or
• Copies of USS photographs.
• See Table 25 Management of Fetal remains/tissue.

PRINT WARNING – Content is continually being revised. ALWAYS refer to the electronic copy for the latest version. Users must ensure that any printed copies of this document are of the latest version. 30
This guideline has been developed for WA Health practice setting only. Clinical content is intended to guide clinical practice and does not replace clinical judgement. Modification will occur according to
internal audit processes and literature review. The rationale for the variation from the guideline must be documented in the clinical record.
Psychological sequelae
Table 20. Psychological healthcare
Aspect Considerations
• There are significant limitations in the evidence examining the
relationships between unplanned pregnancy, abortion, birth, and mental
health. 60
• Emotional responses following abortion are complex and may change over
time.
• Adverse psychological sequelae may be no more likely following abortion
than following continuation of the pregnancy 61.
• For the majority of mental health outcomes, there is no statistically significant
Evidence association between abortion of pregnancy and mental health problems 62, 63,
summary 64
.
• An unintended pregnancy may lead to increased risk of mental health
problems, but it is likely that there are variables in common with risk of
mental health problems and unintended pregnancy 65, 66.
• When a patient has an unplanned pregnancy, rates of mental health problems
will be largely unaffected whether they have an abortion or go on to give birth.
• Patients with a past history of mental health problems may be at increased
risk of further mental health issues after an unplanned pregnancy 67.

• Consider the need for non-judgemental support and care for all women
and pregnant people, and partners, who request an abortion and discuss:
o The importance of seeking support if they experience mental
Recommendation distress/anxiety/health issues or suicidal ideations, particularly if there is
a reported history of mental health issues.
o Involve members of the multidisciplinary team as appropriate; and
o Offer the patient a referral to mental health services, where indicated 68.

Aspect Consideration
• Medications are used to induce the abortion 70.
• May be considered for all gestations of pregnancy as a sole option or combined
with other methods.
• Mifepristone in combination with misoprostol (or misoprostol alone) are the
recommended regimens for medical abortion.
Medical abortion o These medications are indicated for gestations 63 days or less by the TGA
of pregnancy and are taken by patients at home71;
o Medical abortions for gestations greater than 63 days are conducted in a hospital
or clinic setting as an in-patient.
o Refer to Table 30 Medical Abortion Considerations after 63 days.

Vacuum aspiration or surgical dilatation and curettage is generally suitable up to

12 weeks gestation. Greater than 12 weeks gestation, a surgical dilation and
Surgical abortion evacuation is performed by an experienced practitioner 72.
of pregnancy • Anaesthesia depends on service capabilities.
• Refer to Table 37 Considerations for Surgical Abortion.

• Provided by a trained practitioner.

• Usually performed prior to medical abortion where there is a risk of an
unplanned livebirth.
• Strongly recommended by RANZCOG for all abortions 22 weeks gestation and
above as is clinically appropriate 73.
• Post feticide, a person may be transferred to another facility for passage
Feticide of pregnancy if:
o Considered clinically safe.
o There is a robust referral process.
o There is comprehensive documentation.
• Involve the person and the receiving hospital in decisions about transfer.

Selective • If selective reduction or selective feticide is required in multiple

reduction/selective pregnancy, consider the patient’s individual circumstances on a case-by-
feticide case basis.

32
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This guideline has been developed for WA Health practice setting only. Clinical content is intended to guide clinical practice and does not replace clinical judgement. Modification will occur according to
internal audit processes and literature review. The rationale for the variation from the guideline must be documented in the clinical record.
Other considerations for method selection
Table 22. Considerations for selection
Aspect Consideration
• The method of abortion for pregnant people with previous uterine surgery
should be a decision between the person and their clinician as there is
increased risks of complications at time of procedure.
Previous uterine • RANZCOG recommends that for gestations over 14 weeks an USS is
surgery performed to assess for placenta accreta spectrum to assist in planning the
appropriate method and location for the abortion to take place.

• Service capability and capacity should be considered when discussing

method selection, to confirm the patient’s preferred method of abortion is
available.
Service capability • Should there be a change to the patient’s planned abortion care, due to
changes in service capability or capacity, contact the patient immediately
and discuss available options.

• Discuss the complications and risks associated with the differing methods
of abortion in a way the patient can understand.
• Advise of the overall safety of the procedures 74.
• Make a risk assessment of patient’s ability to accurately follow instructions for
Risks and taking medication, and their access to appropriate care in the unlikely event of
complications a medical emergency.
• For early medical abortion <63 days, consider access to working phone and
reliable transport, road access and weather conditions, as well as access to
safe accommodation, including privacy and bathroom facilities and support for
the whole time of the procedure.

• Studies show patient’s experience (measured in satisfaction levels) with medical

and surgical abortion is comparable 75, 76.
• Support the patient to make the decision that is best for their circumstances
Acceptability of and preferences.
method
• Consider additional psychological support for the patient where there is a
need, for those who receive inpatient care within a maternity setting.

33
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This guideline has been developed for WA Health practice setting only. Clinical content is intended to guide clinical practice and does not replace clinical judgement. Modification will occur according to
internal audit processes and literature review. The rationale for the variation from the guideline must be documented in the clinical record.
Section 5: Medical and Surgical abortion risks and complications
Complications and risks associated with abortion are rare when performed by qualified medical
practitioners 77. Serious complications are rare, and morbidity is less common with abortion than with
pregnancies that are carried to term 78.
Table 23. Risks and complications

Aspect Consideration
• Less common following surgical abortion than a medical abortion and are more
common after the first trimester (2–10% of those undergoing abortion in the second
Retained products trimester) 79.
of conception • Requirement for surgical evacuation of retained products increased
following medical abortion, especially with increasing gestation 80.

Infection occurs in 0 to 2 percent of cases of surgical and less than 1 percent of

cases in medical abortion 81.
• Risk reduced if:
Infection o Prophylactic antibiotics prior to surgical abortion 82.
 [refer to Table 37 Considerations for Surgical Abortion].
o Lower genital tract infection has been excluded.

• Rates vary during surgical abortion, however, risk of damage to the external
cervical os at the time of surgical abortion is no greater than 1 in 100 83.
• Decreased risk with84:
o Experienced clinician.
o Use of preoperative cervical priming; and
Cervical trauma o Earlier gestations.
• Increased risk with:
o Age <18; and
o Second trimester procedures.

• Risk is lower at earlier gestations:

Haemorrhage
(requiring o First trimester: less than 1 in 1000 abortions 85;
transfusion) • Greater than 20 weeks: 4 in 1000 abortions 86.

• Risk at the time of surgical abortion is 1–4 in 1000 87.

• Decreased risk of uterine perforation associated with:
Uterine perforation o Experienced clinician.
o Use of pre-operative cervical priming 88.
• Earlier gestations.

• Uterine rupture is a rare but well described serious complication 89.

• More frequently associated with later gestational ages and previous uterine scar.
Uterine rupture
• Risk is less than 1 in 1000 abortions for second trimester medical abortions 90.

34
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This guideline has been developed for WA Health practice setting only. Clinical content is intended to guide clinical practice and does not replace clinical judgement. Modification will occur according to
internal audit processes and literature review. The rationale for the variation from the guideline must be documented in the clinical record.
Aspect Consideration
• Abortion carries a small risk of continued pregnancy (less than 5%)
necessitating another procedure or further intervention.
• More likely following early, rather than late abortion and more likely in medical
Continuing
rather than surgical abortions 91.
pregnancy
• A continued pregnancy following an unsuccessful abortion, while uncommon,
may lead to fetal anomalies if the pregnancy persists 92.

• There are no proven associations between abortion and subsequent ectopic

Future
pregnancy, placenta praevia or infertility 93.
pregnancies

• Standard risks common to all surgical procedures requiring anaesthetic

or sedation.
Surgery, • Consider:
anaesthetic, or
sedation o Individual circumstances and general health of the patient.
• Service capabilities.

35
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This guideline has been developed for WA Health practice setting only. Clinical content is intended to guide clinical practice and does not replace clinical judgement. Modification will occur according to
internal audit processes and literature review. The rationale for the variation from the guideline must be documented in the clinical record.
Section 6: Fetal considerations
Provide information to the patient (as appropriate to the clinical circumstances) about birth and death
registration requirements with the Registry of Births Deaths and Marriages and the management of fetal
remains. For information on the state-wide cremation service and funeral requirements see PathWest
Perinatal Pathology PathWest - (health.wa.gov.au)
Consider the safety of the pregnant person and if there are concerns regarding access to a birth or death
certificate, advise and support the pregnant person to contact the Registry of Births Deaths and Marriages to
discuss options. For information on the Bereavement Centre, see PathWest Bereavement Centre
6.1 Birth registration
Table 24. Registration requirements

Gestation/Birth weight23 Signs of life Requirement

• Birth registration not required.
• Death registration not required.
Less than 20 weeks AND less • Burial/cremation not required.
Not live born Cremation available through Pathwest at
than 400 grams94.
KEMH if desired.
• Parent may request a recognition of
pregnancy loss certificate.
• Birth registration required.
• Death registration required.
• Burial/cremation required.
Less than 20 weeks AND less Live born who
than 400 grams95. subsequently die Births resulting in live born who
subsequently dies at any gestation require a
private cremation or burial.
• Parent may request birth certificate.
• Birth registration required.
• Death registration required.
• Burial/cremation required.
Greater than 20 weeks OR
Not live born Cremation available for all births not live born
more than 400 grams96.
under 28 weeks gestation through Pathwest
at KEMH.
• Parent may request birth certificate.
• Birth registration required.
• Death registration required.
• Burial/cremation required.
Greater than 20 weeks OR Live born who Births resulting in live born who
more than 400 grams97. subsequently die subsequently die at any gestation, or stillborn
at greater than 28 weeks gestation, require a
private cremation or burial.
• Parent may request birth certificate.

Note:
• Babies born alive following an abortion are not reportable to the Coroner.
• Midwives are not required to complete a Notice of Case Attendance form for abortions attended; and
• Birth notifications following an abortion are not to be sent to the Chief Health Officer 98.

36
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internal audit processes and literature review. The rationale for the variation from the guideline must be documented in the clinical record.
6.2 Transport and management of fetal remains
Table 25. Management of fetal remains/tissue

Aspect Consideration
• Where birth and death registration is required, burial or cremation of fetal
remains is required within a cemetery or at a crematorium 99.
• Where birth and death registration is not required:
Lawful disposal o Fetal remains and any products of conception (POC) are to be sent to
Perinatal Pathology for disposal and cremation.
o Fetal remains and POC must not be disposed on in anatomical waste bins.

• Fetal remains that do not legally require burial or cremation may be released
to the patient for private disposal provided that 100:
o There is no risk of transmission of notifiable conditions.
o The patient has been provided with the Patient Information Sheet detailing
Requests to take how the fetal remains may be disposed and has signed the consent form
fetal remains Patient Information Sheet and Consent Form Authorisation and Release of a
home Human Fetus or Placenta (health.wa.gov.au)

See Release of Human Tissue and Explanted Medical Devices Policy

(health.wa.gov.au) for further information.

• Recognise that a patient may wish to make their own arrangements for disposal
within the legal requirements.
• Respect cultural and/or religious beliefs.
• Refer patients to Pastoral care (if available) for information on:
o The options for disposal.
o Funeral services that may assist with burial/cremation where birth
Individual registration is not required, and no death certificate has been issued.
preferences o Memorial services offered through KEMH.
o Information on memory making and commemorative options
o Funeral services that may assist with burial/cremation where birth registration
is required.
• Consider the condition of the fetal remains and inform the patient appropriately.
o Offer social worker or pastoral care support if required.

37
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internal audit processes and literature review. The rationale for the variation from the guideline must be documented in the clinical record.
6.3 Other fetal considerations
Table 26. Fetal considerations

Aspect Consideration
• Provide individualised and holistic care to patients according to circumstances.
• If appropriate, discuss the potential for live birth with the patient.
• Refer to Definition of terms.
Live birth • Establish local procedures for the management of live birth, including palliative
and comfort care 101.
• Offer counselling and support services to patients, partners and
healthcare professionals involved with care of a live born fetus.
• Offer post-mortem examination if clinically indicated (e.g. if fetal abnormality).
• Refer to Stillbirth Centre of Research Excellence: Clinical Practice Guideline for
Fetal autopsy Care Around Stillbirth and Neonatal Death Section 4 Perinatal Autopsy Including
Placental Assessment for more information 102.

• Discuss with patient (as appropriate to clinical circumstance) the following:

o Possibility for live birth.
o Options for memory creation.
o Refer to Table 18. Information and counselling.
o Post-mortem examination, if indicated.
Gestations o Birth registration requirements [see Table 24 Birth Registration requirements].
greater than o Donation of breast milk to milk banks (where appropriate) or lactation
20 weeks suppression.
 Refer to Table 40. Discharge preparation.
• Involve social workers (e.g. for support, discussion of any costs,
funeral arrangements).
• Offer information about community services (e.g. Red Nose Grief and Loss)

38
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This guideline has been developed for WA Health practice setting only. Clinical content is intended to guide clinical practice and does not replace clinical judgement. Modification will occur according to
internal audit processes and literature review. The rationale for the variation from the guideline must be documented in the clinical record.
Section 7: Medical abortion
Medical methods of abortion are safe and effective 103. The below protocol is in line with RANZCOG
Clinical Guideline for Abortion Care.
7.1 Practitioner requirements

MS-2 Step (mifepristone, misoprostol) 104 can be prescribed by any medical practitioner with appropriate
qualifications and training, without the need for certification, including Nurse Practitioners and Endorsed
Midwives for the medical abortion of an intrauterine pregnancy up to 63 days of gestation, in accordance
with the Therapeutic Goods Administration (TGA) regulations and the Public Health Act regulations.

It is recommended that practitioners prescribing MS-2 Step have completed the MS-2 Step training.
ms2step.com.au | This site is intended for healthcare professionals only.

7.2 Medical abortion precautions

Table 27. Precautions for medical abortion
Aspect Consideration
• Hypersensitivity or allergy to prostaglandins or a product component105.
• Suspected or confirmed ectopic pregnancy 106.
Contraindications • Gestational trophoblastic disease.
for medical • Intrauterine device (remove prior to abortion) 107.
abortion
• Obstructive cervical lesions (e.g. fibroids).
• High suspicion of placenta accreta.

• If cardiovascular disease, monitor cardiovascular status as prostaglandins

may cause transient blood pressure changes 108.
• If high risk of uterine rupture:
o Consider individual circumstances.
o May not be suitable with history of caesarean section (CS),
Cautions for multiple pregnancies or uterine abnormalities 109.
medical
• If previous traumatic pregnancy loss (e.g. miscarriage), counsel on blood
abortion
loss associated with medical abortion 110:
o Vaginal bleeding is heavier with medical abortion compared with
surgical abortion and may be comparable to a miscarriage.
• If breastfeeding: abortion medications may cause diarrhoea in the child 111.

• Chronic adrenal failure.

Contraindications • Concurrent long-term corticosteroid therapy.
to mifepristone • Known or suspected haemorrhagic disorders or treatment with anti-
coagulants 112.

39
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This guideline has been developed for WA Health practice setting only. Clinical content is intended to guide clinical practice and does not replace clinical judgement. Modification will occur according to
internal audit processes and literature review. The rationale for the variation from the guideline must be documented in the clinical record.
7.3 Early medical abortion in the outpatient setting
Heath practitioners are advised to refer to current RANZCOG Abortion Care Guidelines 113, as well as the
outlined information below, and adapt to individual patient circumstances.
Table 28. Healthcare setting

Aspect Consideration
To identify the most appropriate setting for early medical abortion consider:
• Local service capability.
• Individual circumstances.
• The patient preference; and
• Discuss where the person will stay during the abortion (3-4 days). Consider
access to working phone and reliable transport, road access and weather
conditions, as well as access to safe accommodation, including privacy and
bathroom facilities and support for the whole time of the procedure.
• Support a decision to access services outside of the patient’s local community
Context if requested.
• If the patient is eligible for an early medical abortion and does not have access
to safe accommodation, they (and an escort) may be eligible for assistance for
travel and accommodation through PATS 114.
• Help with travel and accommodation through PATS is also available for
patients having a surgical abortion of pregnancy.
• Access PATS information through the WA Country Health Website WA
Country Health Service - Patient Assisted Travel Scheme - PATS
(wacountry.health.wa.gov.au/Our-patients/Patient-Assisted-Travel-Scheme-
PATS)

If no local criteria established, outpatient care may be suitable for patients who
meet all of the following:
• Are less than or equal to 9 weeks gestation.
• May be accompanied by a support person, who has been adequately
informed about what to expect, until the termination is complete 115;
• Have access to private facilities required to have an early medical abortion,
including a shower and toilet.
Suggested criteria
• Have immediate access to transport and telephone.
• Can communicate by telephone (e.g. have an interpreter available if required).
• Have the capacity to understand and follow instructions.
• Can access appropriate care in the unlikely event of a medical emergency; and
• Have follow-up arrangements in place – for example consider phone coverage
and access to a working phone, reliable transport, and road access.

40
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This guideline has been developed for WA Health practice setting only. Clinical content is intended to guide clinical practice and does not replace clinical judgement. Modification will occur according to
internal audit processes and literature review. The rationale for the variation from the guideline must be documented in the clinical record.
7.4 Early Medical Abortion pre-dosage care
Table 29. Early medical abortion pre-dosage care

Aspect Consideration
• Perform a pre-abortion assessment:
o Refer to Section 4 Pre-abortion assessment.
• Obtain informed consent:
o Refer to Table 10 Consent.
• Exclude contraindications and review cautions:
o Refer to Early medical abortion precautions.
Clinical care
• Provision of contraception at time of early medical abortion e.g. subdermal
contraceptive implant or follow up appointments for IUD insertion and bridging
contraception.
o Refer to Table 39 Contraception
• Consider the provision of analgesia and antiemetics or scripts for these as per
RANZCOG Guidelines.

• Provide information about:

o The process (e.g. duration, timing of medication, symptoms, passage
of tissue).
• Discuss where the patient will stay during the abortion (3-4 days) considering
their access and support (e.g. a working phone with coverage, reliable
transport, roads, access to safe accommodation, including privacy and
Communication
bathroom facilities and support for the whole time of the procedure).
• Make a risk assessment of the patient’s situation, ability to accurately
follow instructions and their access to appropriate care in the unlikely event
of a medical emergency.
• If indicated, discuss collection of products of conception for examination.

• Provide information about possible medication side effects.

• Common side effects include 116, 117, 118
o Prolonged vaginal bleeding.
o Nausea, vomiting, diarrhoea.
Medication side o Headache.
effects
o Abnormal thermoregulation (e.g. hot flushes, low grade temperature); and
o Abdominal pain and cramps.
• If a patient is breastfeeding, refer to product information.

• Confirm follow-up arrangements.

• Discuss options and preference for contraception.
Follow-up
• Refer to Section 9. Medical and Surgical post-abortion care.

41
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internal audit processes and literature review. The rationale for the variation from the guideline must be documented in the clinical record.
7.5 Early Medical Abortion at 63 days gestation or less
MS-2 Step composite pack is suitable for abortions at 63 days or less gestation (9+0 weeks) 119.
Table 30. MS-2 Step for Early medical abortion
Aspect Consideration
• Consists of:
MS-2 Step
composite o Mifepristone 200 mg (1 tablet containing 200 mg).
120 o Misoprostol 800 micrograms (4 tablets, each tablet containing
pack 200 micrograms).

• For patients less than 49 days gestational age 121:

o Efficacy: 97.4%.
o Incomplete abortion, requiring aspiration: 2.3%.
o Rate of ongoing pregnancy: 0.3%.
Efficacy • For patients with a gestational age between 49 to 63 days 122:
o Efficacy: 95.2%.
o Incomplete abortion, requiring aspiration: 4.8%.
o Rate of ongoing pregnancy: 0.6%.

• Refer to Table 29. Early medical abortion pre-dosage care.

• Provide written information about misoprostol medication self-administration123.
Pre-dosage care
• Supply a prescription for analgesia and antiemetic.

Initial dose:
• Mifepristone 200 mg oral.
Subsequent dose:
124
Dose 36–48 hours after mifepristone:
• Misoprostol 800 micrograms buccal or sublingual.

• Follow-up at 14-21 days as per protocol.

• Confirm expulsion complete 125:
o clinical history (abdominal cramping, pain, history of tissue passed).
Follow-up o serum β-hCG assay, or urine pregnancy test.
o no ongoing persistent vaginal bleeding beyond 21 days.
• Referral for surgical procedure or other follow-up if required.
• Refer to Table 40. Discharge preparation.

Caution: refer to the Australian product information for complete drug information.
20230628-MS2STEP-PI.pdf (mshealth.com.au)

42
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This guideline has been developed for WA Health practice setting only. Clinical content is intended to guide clinical practice and does not replace clinical judgement. Modification will occur according to
internal audit processes and literature review. The rationale for the variation from the guideline must be documented in the clinical record.
7.6 Medical abortion after 63 days gestation
A combination regimen with a prostaglandin analogue is more effective than use of either medication as
a single analogue agent 126.

Care during medical abortion

Table 31. medical abortion considerations after 63 days gestation

Aspect Consideration
• Feticide advised for gestations greater than 22 weeks.
• If mifepristone use is contraindicated, seek expert advice on misoprostol-
only regimen.
Cautions
• If misoprostol use is contraindicated, consider cervical ripening with
transcervical balloon and oxytocin.

• Refer to Table 29 Early medical abortion pre-dosage care.

• Baseline observations, vaginal loss, pain prior to commencement.
• IV access is recommended.
• If Rh negative and gestational age of 10+0 weeks and over, recommend Rh
Pre-care D Immunoglobulin 127.
• Full blood count (FBC), Iron Studies and Group and Hold.
• USS

• Offer analgesia.
• Offer antiemetics if required.
• Vaginal examination as clinically indicated.
Inpatient • Bed rest for 30 minutes after each dose but may mobilise freely at other times.
clinical care • Consider oxytocin IM at time of birth.
• If the placenta is not spontaneously delivered within 30 minutes of the fetus (or
earlier if excessive bleeding occurs) or if blood loss is 300mls or above, notify
Senior Medical Officer to consider operative removal.

• Prior to initial dose of misoprostol and then every 4 hours, unless the patient’s
condition dictates more frequent observations:
o Observations, vaginal loss, contractions, assess pain.
Observations • Post birth, every 15 minutes for the first hour after delivery and then as often as
dictated by the patient’s clinical condition.
o Observations, vaginal loss, and conscious state.

43
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internal audit processes and literature review. The rationale for the variation from the guideline must be documented in the clinical record.
Medical abortion for patients at risk of uterine rupture
See Table 21 Considerations for selection. There is a small increase in risk of uterine perforation or rupture
for both surgical and medical methods in the second trimester for patients with previous uterine surgery.
Refer to local protocol for medical management of abortion in the second trimester 128.
For patients >20 weeks with previous uterine surgery, seek expert opinion on medical abortion protocol and
management 129.

Refer to an Australian pharmacopoeia for complete drug information.

Medical abortion regimen for patients not known to be at risk of uterine rupture.
The following medical regime is in accordance with RANZCOG Clinical Guidelines for Abortion Care
(2023) 130.
Table 32. Medical abortion with no known risk of uterine rupture
Follow protocol according to gestational age
• Day 1: mifepristone 200 mg oral
Up to 10 weeks • Day 2: 24–48 hours after mifepristone:
weeks o Misoprostol 800 micrograms vaginal, sublingual, or buccal.

• Day 1: mifepristone 200 mg oral

• Day 2: 36–48 hours after mifepristone
10+1 – 20 o Misoprostol 800 micrograms vaginal or 600 micrograms sublingual.
weeks o Repeat doses of misoprostol 400 micrograms (vaginally, sublingually, or
buccally) every three hours until expulsion of pregnancy.

For medical abortions after 20 weeks pregnant an adjusted regime with lower
Greater than 20 doses of misoprostol and longer intervals is recommended, in accordance with
weeks local guidelines.

Caution: refer to the Australian product information for complete drug information

44
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This guideline has been developed for WA Health practice setting only. Clinical content is intended to guide clinical practice and does not replace clinical judgement. Modification will occur according to
internal audit processes and literature review. The rationale for the variation from the guideline must be documented in the clinical record.
Section 8: Surgical abortion
Surgical curettage is generally suitable for gestations up to 12 weeks. Gestations beyond this require a
clinician with the relevant training and experience 131.
8.1 Surgical abortion pre-procedure care
Table 33. Surgical abortion pre-procedure care
Aspect Considerations
• Perform a pre-abortion assessment including baseline observations:
o Refer to Section 4 Pre-abortion assessment.
• Obtain informed consent:
o Refer to Table 10 Consent.
Clinical care • Consider the need for Rh D immunoglobulin:
o Refer to Table 38. Post-abortion care considerations.
• Consider the need for cervical priming 132:
o Refer to Table 34. Cervical priming for surgical abortion.

• Provide information about:

o The abortion process.
Communication o What symptoms to expect post procedure including bleeding and pain; and
o Refer to Table 18 Information and counselling.

8.2 Cervical priming for surgical abortion

Table 34. Cervical priming for surgical abortion
Aspect Considerations
• Cervical preparation decreases the length of surgical abortion procedure.
• May also 133:
Rationale o Reduce complications of uterine perforation and cervical injury.
o Make the procedure easier to perform.
Make the procedure more comfortable for the patient.

• Pharmacological agents:
o Mifepristone and misoprostol.
Options o Misoprostol alone.
• Osmotic dilators:
Dilapan-S dilators.

• Recommended:
o For patients less than 18 years of age.
Recommendation o For nulliparous pregnant people.
o After 12–14 weeks gestation 134 (although may be considered at
any gestational age).

45
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This guideline has been developed for WA Health practice setting only. Clinical content is intended to guide clinical practice and does not replace clinical judgement. Modification will occur according to
internal audit processes and literature review. The rationale for the variation from the guideline must be documented in the clinical record.
Caution: refer to the Australian product information for complete drug information.

Misoprostol prior to surgical abortion

The following medical regime is in accordance with RANZCOG Clinical Guidelines for Abortion Care
(2023) 135.
Table 35. Misoprostol alone for cervical priming prior to surgical abortion up to 14 weeks gestation.
Aspect Considerations
Precautions • Refer to Table 27. Precautions for medical abortion.
Dosage and timing of misoprostol prior to surgery may vary based on practitioner
preference, gestation, and risk factors for difficult dilatation.
Misoprostol can be administered buccally, sublingually, and vaginally. Avoid the oral
route due to increased risk of gastrointestinal side effects.
Suggested dosing:
Dosage 1–3 hours prior to surgery
• 400 micrograms vaginally, sublingually, or buccally
• If misoprostol is unable to be used, then suggest mifepristone 200mg orally 24-
48 hours prior to procedure.

Caution: refer to the Australian product information for complete drug information

Mifepristone and misoprostol prior to surgical abortion

The following recommendation is in accordance with RANZCOG Clinical Guidelines for Abortion Care
(2023) 136
Table 36. Mifepristone and misoprostol for cervical priming prior to surgical abortion from 14 – 24 weeks
gestation.

Aspect Considerations
• Refer to Table 27. Precautions for medical abortion.
Precautions • There may be an increased risk of pre-operative expulsion of pregnancy
with mifepristone and misoprostol prior to surgical abortion 137.

• May occur as an outpatient (or at home) following pre-abortion assessment.

Pre-dose care
• Provide contact details to the patient in case of emergency.
• For patients having a surgical abortion from 14-24 weeks gestation, it is
reasonable to offer either osmotic dilators alone (or in combination with
mifepristone), misoprostol alone, or a combine regimen of mifepristone and
Recommendation misoprostol.
• It is noted that the addition if misoprostol to osmotic dilators may lead to
increased side effects at later gestations without obvious benefit.

46
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internal audit processes and literature review. The rationale for the variation from the guideline must be documented in the clinical record.
Caution: refer to the Australian product information for complete drug information.

See Appendix A for considerations for osmotic dilators for cervical priming prior to surgical abortion.

8.3 Surgical abortion of pregnancy

Table 37. Considerations for surgical abortion.

Aspect Considerations
• Suction evacuation:
o commonly performed up to 12+0 weeks gestation.
o experienced practitioners up to 16+0.
Methods • Dilatation and evacuation (D&E):
o usually performed after 12+0 weeks (depending on
practitioner experience and equipment availability).
• Upper gestational limit dependent on practitioner experience 138.

• Intra or perioperative prophylactic antibiotics recommended, for those who

have not been appropriately investigated 139, 140.
• In the absence of local protocols consider RANZCOG Best Practice Statement:
Prophylactic antibiotics in obstetrics and gynaecology 2021 141.
Prophylactic • If medication allergy refer to Therapeutic Guidelines for alternate
antibiotics antibiotic regime 142, 143;
• Consider opportunistic healthcare including cervico-vaginal screening for STI
and syphilis serology.
• Refer to Table 17. Clinical assessment prior to abortion.

• Method may depend on service capabilities and the patient’s choice.

• May be performed with or without oral or intravenous anxiolytic.
Anaesthesia
• Analgesics, local anaesthesia and/or mild sedation are usually sufficient.

• May decrease the risks of haemorrhage but not routinely recommended

Oxytocic agents for suction evacuation.

• May be used to check completeness.

• Routine use not required at less than 12 weeks 144.
USS • Routine use with dilatation and evacuation (D&E) to reduce rate of uterine
perforation 145.

• Examination of the products of conception by the surgeon may assist with

recognition of gestational trophoblast 146.
Examination of • Examination and identification of fetal parts by practitioner is advised with
tissue D&E for confirmation of complete evacuation 147.
• Histopathology if clinically indicated:
• Refer to Table 38. Post-abortion care considerations.
47
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internal audit processes and literature review. The rationale for the variation from the guideline must be documented in the clinical record.
Aspect Considerations

• Consider provision of contraception at time of surgical abortion

Contraception - i.e., insertion of IUD or subdermal contraceptive implant 148

• Pain: analgesia is usually required (e.g. non-steroidal anti-inflammatory drugs).

• Bleeding: expected duration 5–18 days 149.
Side effects
• Nausea: usually related to prostaglandins or anaesthetic drugs 150.

• Serious complications are rare151.

Risks and
complications • Risk rises with operator inexperience and gestational age 152.

• Recommend follow up (e.g. GP, telephone/video contact, face to face) to

discuss:
o Bleeding.
Follow-up o Psychological well-being.
o Contraception [refer to Table 39. Contraception provision].
• Refer to Table 40 Discharge preparation.

Caution: refer to the Australian product information for complete drug information.

48
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This guideline has been developed for WA Health practice setting only. Clinical content is intended to guide clinical practice and does not replace clinical judgement. Modification will occur according to
internal audit processes and literature review. The rationale for the variation from the guideline must be documented in the clinical record.
Section 9: Medical and Surgical post-abortion care
Most serious complications are detectable in the immediate post-procedure period. Refer to Table 23.
Risks and complications. Appropriate and accessible follow-up care is essential 153.
Table 38. Post-abortion care considerations
Aspect Considerations
• Provide routine post-procedural care including assessment of
Inpatient post- observations, consciousness, and observation of vaginal loss.
procedural • If possible, consider providing inpatient care that is not within a maternity
care service environment.

• Recommend Rh D immunoglobulin (Anti-D) to all Rh D negative patients

within 72 hours of abortion >10 weeks gestation 154, unless the fetus is known
to be Rh negative.
• Anti-D prohylaxis not recommended for medical abortion performed under
10+0 gestation 155.
• Gestations up to 12+6 weeks (SToP) —250 IU Rh D immunoglobulin
via intramuscular (IM) injection 156.
Rh prophylaxis*
• Gestations 13+0 weeks or more—625 IU Rh D immunoglobulin via
intramuscular (IM) injection 157.
• If greater than 20 weeks gestation, recommend quantification of feto-maternal
haemorrhage (FMH) 158.
• If FMH estimated at 6 mL or more, recommend additional dose according to
FMH quantification.

• Individually determine analgesia requirements after surgical abortion or

during and after medical abortion, as requirements vary.
• Offer medication for pain management 159 (paracetamol and/or ibuprofen
often effective).
Analgesia • Advise patients that severe pain may be indicative of uterine perforation or clot
retention 160.
• Seek advice if analgesia provided unable to manage pain effectively.

• If clinically indicated or suspicion of fetal abnormality, consider

histopathological examination and chromosomal analysis (microarray) of
Histopathology
tissue obtained during abortion procedures.

Caution: refer to the Australian product information for complete drug information.

9.1 Contraception
Australia has a relatively high rate of unintended pregnancy 40-50% 161. Australia ranks amongst the
highest countries for abortion in the developed world, with 1 in 4 people undergoing an abortion
procedure 162.

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internal audit processes and literature review. The rationale for the variation from the guideline must be documented in the clinical record.
Table 39. Contraception provision

Aspect Considerations
• Prevention of unwanted future pregnancies is an important part of the
provision of abortion healthcare.
Context • Patients who do not attend follow-up appointments for contraception are at
higher risk of unintended pregnancy than patients who have contraception
provided at time of abortion 163.

• Ideally, commence discussions about contraception during first contact.

• Discuss options based on the patient preference including short and long-
acting methods.
• Provide information on side effects, benefits and failure rates of methods using
WNHS Contraception information sheet Contraceptives-methods-poster.pdf
(health.wa.gov.au)
Information • Offer information on benefits of condom use in preventing STI.
• If contraception declined, offer information (as appropriate to the
circumstances) about:
o Types of contraception available.
o Accessing local services for contraceptive advice or support; and
o The importance of prevention of future unwanted pregnancies.

• Significantly less likely to result in unintended pregnancy than short-acting

Long-acting user- dependent methods, such as the oral contraceptive pill 164, 165.
reversible • May be inserted, during a surgical abortion, at time of early medical abortion,
contraception i.e. subdermal implant, or at post medical or surgical abortion follow up 166.
• Provide information on what to expect after insertion.

9.2 Discharge preparation and follow-up

Table 40. Discharge preparation

Aspect Considerations
• Promote continuity of care to facilitate the development of longer- term
support opportunities.
• Provide information on accessing support agencies/organisations
appropriate to individual circumstances (e.g. GP, grief counselling or
support groups).
• Offer referral for counselling, especially where risk factors for long- term
post-abortion distress are evident (e.g. ambivalence before the abortion,
Counselling and
lack of a supportive partner, psychiatric history, membership of a religious
support
or cultural group where abortion is not an option, or faith or cultural
complexities relating to abortion).
• Offer information and assistance as appropriate regarding birth
registration and funeral arrangements:
o Refer to Table 24. Registration requirements.
o Refer to Table 18. Information and counselling.

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internal audit processes and literature review. The rationale for the variation from the guideline must be documented in the clinical record.
Aspect Considerations
• If appropriate, discuss the possibility of lactation including:
o suppression (pharmacological and comfort measures).
Lactation o donation of breast milk to milk banks.
o emotional response to lactation.

• To reduce risk of infection, recommend (until bleeding ceased)

avoiding:
Risk of infection o Vaginal intercourse.
o Insertion of tampons or other products into the vagina.
o Bathing or swimming.

• If there are no physical, psychological, health related or other barriers after

an abortion, conception can be attempted immediately following the
Subsequent abortion.
pregnancy • If appropriate offer information about pre-conception care (e.g. folic acid,
smoking cessation, rubella immunisation if required).

• Determine timing of discharge on an individual basis.

• Consider routine discharge criteria (e.g. observations, recovery from
effects of sedation/anaesthesia).
• Supply a prescription for analgesia and/or antiemetics (relevant to
method of abortion).
• Provide written information regarding post-procedure symptoms and
Discharge accessing appropriate care in the unlikely event of a medical
emergency 167.
Provide a confidential discharge summary to the patient that gives sufficient
information about the procedure to allow another practitioner elsewhere to
deal with any complications (particularly for people living in rural and remote
locations).

• Seek consent for discharge summary distribution (e.g. to GP) and for
discharge/medical information to be uploaded to My Health Record. Ensure
this information is clearly understood as clinics in remote communities are
often staffed by friends or family of the patient.

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internal audit processes and literature review. The rationale for the variation from the guideline must be documented in the clinical record.
Aspect Considerations
• After medical abortion, recommend follow-up within 14-21 days 168
(e.g. GP, telephone/video contact, face to face).
• Various methods recommended to confirm completion of medical
abortion 169:
o Assessment of symptoms.
o Quantitative β-hCG.
o low sensitivity urine β-hCG.
o USS if indicated.
• After surgical abortion, offer follow-up based on individual circumstances
(e.g. if procedure complicated or additional support required).
Follow-up • If appropriate:
o Schedule follow-up to discuss pathology results, especially where
there was histopathology/autopsy for fetal abnormality.
o Recommend referral to medical specialists (e.g. clinical genetics
services).
• Where follow up is difficult, or uncertain encourage the patient to seek
support from GP or local health service for:
o Passage of tissue.
o Ongoing bleeding and/or pain.
o Contraception.

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internal audit processes and literature review. The rationale for the variation from the guideline must be documented in the clinical record.
Definitions
The following definition(s) are relevant to these guidelines.

Abbreviations
Term Definition
β-hCG Beta human chorionic gonadotropin
FMH Feto-maternal haemorrhage
GP General Practitioner
PATS Patient Assisted Travel Scheme
Rh D Rhesus immunoglobulin
SARC Sexual Assault Resource Centre
STI Sexually transmitted infection(s)
USS Ultrasound scan

Definition of terms
Term Definition
A person registered under the Health Practitioner Regulation National Law to
Aboriginal and Torres practice in the Aboriginal and Torres Strait Islander health practice profession
Strait Islander Health (other than as a student).
Practitioner
The Public Health Act 2016defines abortion as any act done with the intention
Abortion of causing the termination of a pregnancy.

In this document abortion healthcare refers to the provision of healthcare by a

Abortion healthcare healthcare professional that supports a patient to abort a pregnancy.

Chief Health Officer The person designated as the Chief Health Officer under Part 2, Division 1,
(CHO) section 11 of the Public Health Act 2016.
The use of non-physical tactics and/or physical tactics to make a person
Coercive control subordinate and maintain dominance and control over every aspect of life,
effectively removing personhood.
May be one in which, in the judgement of the treating health practitioner(s),
there are circumstances that complicate the decision-making process and/or
care and management of a patient requesting an abortion of pregnancy.
This may include (but is not automatically a requirement of or limited to)
Complex case issues related to a woman or pregnant person’s medical, social, or
economic circumstances, capacity to consent, mental health, congenital
anomalies, age, or gestation of pregnancy at which termination of
pregnancy is requested.

Conscientious A registered health practitioner who declines to advise or provide or

objector participate in a lawful treatment, procedure, or practice, because it conflicts
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internal audit processes and literature review. The rationale for the variation from the guideline must be documented in the clinical record.
with their own personal beliefs and values 170, 171.
Early medical Early medical abortion refers to medical abortion of pregnancy under 9 weeks
abortion (63 days).

Family violence This term includes the impact violence has on kinship and family ties and the
broader community. It can also refer to violence across and within families
such as child abuse and elder abuse. Such violence can also involve
stressors that lead to self-harm and suicide.

Healthcare Any healthcare provider involved in the care of a patient requesting

professional termination of pregnancy (i.e., includes social worker, counsellor, Aboriginal
health worker, liaison officer as well as medical officer and authorised nurse
or midwife).

Long-acting At the time of a surgical termination of pregnancy all forms of long-acting

reversible reversible contraception may be inserted including intrauterine devices
contraception (Copper bearing or Levonorgestrel varieties) injections or subdermal
implants.
At the time of medical termination of pregnancy implants and injections may
be utilised immediately.

Live birth Describes a fetus where there are signs of life after birth of the fetus is
completed, regardless of gestation or birthweight 172.

Signs of life may include: beating of the heart, pulsation of the umbilical cord,
breath efforts, definite movement of the voluntary muscles, any other
evidence of life 173, 174

Multidisciplinary team Membership of the multidisciplinary healthcare team is influenced by the

needs of the patient, availability of staff, and other local resourcing issues.
May include but is not limited to: nurse, midwife, obstetrician, general
practitioner, feto-maternal specialist, social worker, psychologist, counsellor,
or Aboriginal liaison officer.

Observations In this document observations includes respiratory rate (RR), blood pressure
(BP), heart rate (HR), oxygen saturations (SpO2), temperature (T) and level
of consciousness (LOC).

Obstetrician Local facilities may, as required, differentiate the roles and responsibilities
assigned in this document to an ‘Obstetrician’ according to their specific
practitioner group requirements; for example, to gynaecologists, general
practitioner obstetricians, specialist obstetricians, consultants, senior
registrars, and obstetric fellows.

Patient Refers to a person receiving or registered to receive medical treatment (in

this instance the person requesting the abortion).

For noting, in this guideline a patient can otherwise be referred to as a girl,

woman/women, young person, young pregnant person, consumer or client.

Patient Assisted Referred to as PATS, a subsidy program that provides financial help for travel
Travel Scheme and accommodation expenses when travelling long distances to see an
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internal audit processes and literature review. The rationale for the variation from the guideline must be documented in the clinical record.
approved medical specialist.

The patient accessing termination of pregnancy (and an escort) may be

eligible for assistance with travel and accommodation if they do not have
access to safe, private accommodation.

The patient will be covered under the PATS program until the patient is
discharged by a suitably qualified medical practitioner.

Any further follow up appointments required for this procedure will also be
eligible for PATS.

Performing an Refer to Section 1.1 Performing of an abortion.

abortion

Pregnant person An inclusive term used in the clinical setting prior to the client revealing
preferred pronouns.

Registered health In Australia, health practitioners are registered under the Health Practitioner
practitioner Regulation National Law. This sets out a framework for the registration and
discipline of registered health practitioners and establishes National Boards
that set standards, codes and guidelines that registered health practitioners
must meet.

Reproductive control Behaviours that interfere with women or pregnant person’s reproductive
autonomy as well as any actions that pressurise or coerces a patient into
initiating or terminating a pregnancy.

Student health In this document, refers to a person enrolled in an approved program of

practitioner study, undertaking clinical training and who is authorised as a student with
their respective Health Practitioner National Board.

Young person A young person refers to a woman or pregnant person aged less than 18
years.

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This guideline has been developed for WA Health practice setting only. Clinical content is intended to guide clinical practice and does not replace clinical judgement. Modification will occur according to
internal audit processes and literature review. The rationale for the variation from the guideline must be documented in the clinical record.
Document History
Document
metadata
Document Owner Frances Downey, A/Director, Health Networks Directorate, Clinical
Excellence Division, WA Department of Health
Document Approver Sheralee Tamaliunas, Acting Assistant Director General, Clinical Excellence
Division, WA Department of Health
Author Adapted from Queensland Clinical Guideline: Termination of Pregnancy,
October 2019. Doc No: MN19.21-V9-R24
HEALTHINTRA-ID TBC
Content Manager ID TBC
Version Number: | Version: Approved Date:
{_UIVersionString} | Review Date: 02/04/2025
DO NOT EDIT THIS FIELD 03/04/2024
Version Updated for release of Approved Date:
online consultation on 01/11/2024 Review Date: 02/04/2026
28/10/2024

National Safety and Quality Health Service standards

National Safety and Quality Health Service
standards

Clinical Partnering Preventing Medication Comprehensive Communicating Blood Recognising

Governance with and Safety Care for Safety Management &
Consumers Controlling Responding
Healthcare to Acute
Associated Deterioration
Infection

☒ ☒ ☒ ☒ ☒ ☒ ☒ ☒

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internal audit processes and literature review. The rationale for the variation from the guideline must be documented in the clinical record.
Appendices
Appendix A: Osmotic dilators for surgical priming prior to surgical abortion.

Aspect Considerations
• Dilapan-S:
o Synthetic osmotic dilators made of a polyacrylate based proprietary
hydrogel (Aquacryl).
o Achieves close to maximum dilation effect at 4-6 hours – most suited for
same day evacuation.
o More predictable dilatation compared to Laminaria175.
Types of osmotic • Laminaria:
dilators o Non-synthetic osmotic dilators made up of dehydrated and sterilised stems
of the seaweed Laminaria Japonica and Laminaria Digitata.
o Achieve maximum dilation effect at 12-24 hours.
o Dilators should not be left in place for more than 24 hours 176.
o Theoretical risk of allergy and infection due to organic material 177.

• Osmotic dilators are a suitable non-pharmacological method of cervical

priming prior to surgical abortion after 14+0 weeks gestation.
Indication
• Osmotic dilators are the preferred method of cervical priming after 19+0 weeks.

• Offer insertion of osmotic dilators (with or without adjuvant mifepristone or

misoprostol) the day before the surgical abortion.
• Osmotic dilators can be used in setting of ruptured membranes, with
appropriate antibiotic cover 178.
• Osmotic dilators can be used in setting of placenta praevia 179.
• There is no clear evidence to guide the appropriate number of osmotic
dilators required for cervical ripening. The number of osmotic dilators
inserted tend to increase with gestation but is often based on provider
Timing experience and preference 180.
• For gestations over 20+0, further insertion of osmotic dilators may be required if
adequate dilatation is not achieved.
• A surgical abortion following same day insertion of osmotic dilator, usually 4-6
hours prior to procedure, should only be performed by experienced
practitioners. Consider Dilapan-S over Laminaria, and use of adjuvant
mifepristone or misoprostol, when considering dilation and excavation of
same-day insertion of osmotic dilators 181.

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This guideline has been developed for WA Health practice setting only. Clinical content is intended to guide clinical practice and does not replace clinical judgement. Modification will occur according to
internal audit processes and literature review. The rationale for the variation from the guideline must be documented in the clinical record.
Aspect Considerations
• Practitioners may combine use of osmotic dilators with mifepristone or
misoprostol for improved cervical ripening and reduced duration between
cervical ripening and surgical abortion to accommodate time constraints of
patient and health service, especially after 19+0 week gestation.
Combination with • Combined use of mifepristone AND misoprostol may increase risk of pre-
mifepristone or procedural expulsion of fetus 182.
misoprostol • Mifepristone can be given the same day of osmotic dilator insertion, if used
as adjuvant cervical priming agent.
• Buccal or sublingual misoprostol should be given 3 hours before surgical
abortion if used as adjuvant cervical ripening agent 183.

• Method may depend on service capabilities and the patient choice.

• May be performed with or without oral or intravenous anxiolytic.
Anaesthesia
• Analgesics, local anaesthesia and/or mild sedation are usually sufficient.

• Prophylactic antibiotics are not required during insertion of the synthetic

osmotic dilator, Dilapan-S.
Prophylactic
• The product information for Laminaria recommends prophylactic antibiotic
antibiotics
with insertion of Laminaria 184.

• Migration and fragmentation of osmotic dilators may result in retained dilators in

the uterus. Although rare, retained osmotic dilators can lead to infection and
Precautions bleeding complications.
• Advise patient to collect and bring with them on the day of procedure any
osmotic dilators that have been spontaneously expelled.

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This guideline has been developed for WA Health practice setting only. Clinical content is intended to guide clinical practice and does not replace clinical judgement. Modification will occur according to
internal audit processes and literature review. The rationale for the variation from the guideline must be documented in the clinical record.
Appendix B: Aboriginal Clients: Cultural Considerations
WA Health recognises that a culturally safe and responsive health system is imperative to ensuring Aboriginal
and Torres Strait Islander (Aboriginal 1) West Australians receive the healthcare required to significantly improve
health and social and emotional wellbeing outcomes. To ensure the unique rights and needs of Aboriginal people
are recognised, the provision of culturally secure and respectful care 185 will embrace a strengths-based
paradigm 186, kinship and Aboriginal culture as a protective factor. For Aboriginal girls and women, childbearing
maintains culturally significant ancestral and familial connections 187. A decision to terminate a pregnancy is
impactful. This can be immediately or in the long-term.

Recognition of intergenerational, institutional, collective, and historical trauma is important. In addition, racism,
cultural load 188, and the differences between mainstream systems and more holistic Aboriginal understandings of
social and emotional health and wellbeing 189, need to be understood and respected.

Women’s Business
Aboriginal women continue their support and nurturing of a young girl until she becomes a woman, when she
then provides the same role to younger generations of girls. This special knowledge is preserved through
women’s business 190.

For Aboriginal women or girls, to terminate a pregnancy by having an abortion can be regarded as a sensitive
and complex topic. To be supportive, where possible, offer access to female medical health practitioners. Where
this is not possible, offer the Aboriginal women or girls to nominate a female support person to be present for all
parts of the health care journey, if she feels she needs this level of support.

The power of kinship and spiritual safety

There is significant power in Aboriginal kinship connections which supports the holistic strengthening of women’s
wellbeing. Strong kinship systems are known to improve the maternal health of Aboriginal girls and women 191.

Culturally Safe Practices

Provide culturally safe practices and support for girls and women who identify as Aboriginal is critical. Improving
cultural safety can improve access to, and the quality of health care. This manifests as a health system that
demonstrates respect for Aboriginal cultural values, strengths, and differences, and also addresses racism and
inequity. Importantly, it requires self-understanding, truly knowing and accepting our own culture and its
influence on how we think, feel, and behave. The impact of one’s dominant culture on another is complex - and
often goes unquestioned - but lies at the heart of cultural safety.
This can be supported via formal professional development and training of all staff in cultural awareness.

Cultural responsiveness
Cultural responsiveness is the active approach taken by individuals, organisations, and systems to promote and
maintain cultural safety. It is a negotiated process of what constitutes culturally safe health care as decided by
the woman receiving the care. It requires strengths-based approaches and recognises that if culture is not
factored into health care and treatment, the quality and probable impact of that care and treatment is likely to be
diminished 192.

Having a yarn can be helpful when a girl or woman is thinking about their care options and deciding the best way
forward. To ensure a culturally safe and responsive practice is provided, below is a list of considerations for
guidance. It is essential to:

1
Use of the word “Aboriginal” Using the term – Aboriginal Within Western Australia, the term “Aboriginal” is used in preference to “Aboriginal and Torres Strait Islander” in recogni�on that Aboriginal people are the original inhabitants of Western Australia. “Aboriginal and
Torres Strait Islander” may be referred to in the na�onal context, and “Indigenous” may be referred to in the interna�onal context. No disrespect is intended to our Torres Strait Islander colleagues and community.

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internal audit processes and literature review. The rationale for the variation from the guideline must be documented in the clinical record.
• Ensure that all support is provided with confidentiality for the Aboriginal woman, or girl (noting Section 3.2
of the Guidelines). Ensure this is said openly to provide assurance, reduce shame and stigma. Ensure
your organisational Code of Conduct is adhered to.
• Yarn with the Aboriginal woman or girl about what is best for them. If consented to, include support
people such as a partner, the young girl’s parent/s, or others.
• Respect an Aboriginal girl’s or woman’s cultural identity while providing good communication,
empowerment in decision making and inclusion of supportive people valued in her care.
• Offer support from female culturally appropriate staff, such as an Aboriginal Health Practitioner or an
Aboriginal Liaison Officer. Or offer co-care with female health practitioners from mainstream health
support services or an Aboriginal Community Controlled Health Organisation.
• Be mindful of coercion. Remind a woman they are in control of their decisions and body. Provide
additional information particularly if terminology is not new to the woman or girl. Offer support and if
appropriate, ask if they would like a referral for aftercare support.
• Understand cultural determinants of health 193, the strength and importance of family, kin, the impact for a
girl or woman being ‘off-country’ particularly the differences of cultural practice, or if unaccompanied by
family and other support people.
In WA, practitioners operate with the Australian Health Practitioner Regulation Agency (AHPRA) registration
system. The creation of a culturally safe notification process, led by Aboriginal and Torres Strait Islander
Peoples, is a major milestone 194 in the implementation of the National Scheme’s Aboriginal and Torres Strait
Islander Health and Cultural Safety Strategy 2020-2025 195 and aligns to:
o AHPRA Aboriginal-and-Torres-Strait-Islander-Employment-Strategy-2020-2025 196
o National Safety and Quality Health Service Standards User Guide for Aboriginal and Torres Strait
Islander Health 197
In WA, each Health Service Provider provides direction to staff by:
1. having a Code of Conduct
2. implementing policy and strategic direction, such as but not limited to:
a. WA Health and Wellbeing Framework 2015 - 2030 198
b. National Agreement on Closing the Gap 199, in particular the priority reforms 200
c. WA Aboriginal Empowerment Strategy 201
d. Aboriginal Health Impact Statement and Declaration Policy 202
3. providing education and training to uplift cultural competency of staff.

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This guideline has been developed for WA Health practice setting only. Clinical content is intended to guide clinical practice and does not replace clinical judgement. Modification will occur according to
internal audit processes and literature review. The rationale for the variation from the guideline must be documented in the clinical record.
Appendix C: Culturally Diverse Clients: Cultural Considerations
The WA Department of Health (WA DoH), Clinical Excellence Division has a Cultural Diversity Unit (CDU) within
the Health Networks Directorate. The CDU develops and promotes policies, practices and services that
strengthen the cultural competency of WA health staff, and improves accessibility, safety, and quality of services
for people of culturally and linguistically diverse (CaLD) backgrounds. This includes improving health literacy and
better health outcomes for CaLD communities.

Many resources for health professionals can be found on the WA DoH website: Multicultural health 203 and within
the ‘Resources and services’ section is a link to the 2015 Resource toolkit for refugee and migrant women
accessing maternity services 204. The toolkit is to support clinicians to deliver timely, safe, quality, and competent
care for refugee and migrant women.

Whilst dated, the principles and overarching guidance in the toolkit remains relevant and useful for clinicians to
refer to. However, abortion is not mentioned in the toolkit.

Therefore, the following checklist has been provided by the WA DoH in consultation with CaLD community
organisations to assist those caring for women and families requiring abortion care.

MULTICULTURAL ABORTION CARE CONSIDERATIONS CHECKLIST

• The individual seeking care has been provided with opportunity to codesign the plan of care.
• To the extent that the individual wants support and consents to appropriate community representation
from spouse, family members, and community leaders is enabled.
• Care is provided in the context of cultural needs and with sensitivity to the individual’s own level of
engagement and interpretation of the cultural community societal norms (mores).
• General community policy has been adapted to meet the individuals own cultural needs.
• Care providers consider the specific needs of CaLD groups when developing and evaluating operational
policy.
• Communication is clear and accessible for the individual and as appropriate, their spouse, family
members, and community leaders. It is important to note that often it is only the men in the family who
learn English and the person requiring abortion care may not want a man to be aware. It is therefore
essential that all care is described and planned in language that is accessible to the individual requiring
the service and if needed always via professional interpretation services.
• The health care providers caring for this person have had cultural awareness training supported by as a
minimum:
o a multicultural competency and capacity framework
o access to professional language services.

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This guideline has been developed for WA Health practice setting only. Clinical content is intended to guide clinical practice and does not replace clinical judgement. Modification will occur according to
internal audit processes and literature review. The rationale for the variation from the guideline must be documented in the clinical record.
Appendix D: Family and Domestic Violence (FDV) Pathway

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internal audit processes and literature review. The rationale for the variation from the guideline must be documented in the clinical record.
Appendix E: Acknowledgements
Acknowledgements - Queensland
The Queensland Clinical Guidelines (QCG) gratefully acknowledge the contribution of Queensland
clinicians and other stakeholders who participated throughout the guideline development process.

Working Party Clinical Lead

Associate Professor Rebecca Kimble, pre-eminent Staff Specialist, Obstetrics & Gynaecology, Royal
Brisbane and Women’s Hospital
Dr Renuka Sekar, clinical lead, Maternal Fetal Medicine Specialist, Royal Brisbane and Women’s Hospital

QCG Program Officer

Ms Emily Holmes Ms
Jacinta Lee

Working Party Members

Dr Tegan Allin, Rural Generalist, Torres and Cape Hospital and Health Service
Mrs Josephine Bell, Registered Midwife, Maternity Unit, Stanthorpe Hospital
Dr Elize Bolton, Clinical Director, Obstetrics and Gynaecology, Bundaberg Hospital
Mrs Kym Boyes, Nurse Practitioner, Community Health, Torres Cape HHS
Ms Bronwyn Brabrook, Advanced Social Work, Women’s, Children’s, and Emergency, Toowoomba
Hospital
Mrs Susan Callan, Clinical Nurse Midwife Consultant, Bereavement, Royal Brisbane and Women's
Hospital
Mrs Katie Cameron, Consumer Representative, Maternity Consumer Network
Ms Eileen Cooke, Parent Support, Preterm Infants Parent Association (PIPA)
Professor Caroline De Costa, James Cook University, College of Medicine
Ms Andrea Densley, Nurse Unit Manager, Child Health, Department of Health
Mrs Carole Dodd, Registered Midwife/Clinical Nurse, Pregnancy Loss, Caboolture Hospital
Associate Professor Greg Duncombe, Senior Staff Specialist, Maternal Fetal Medicine, Royal Brisbane and
Women's Hospital
Ms Joanne Ellerington, Manager, Data Collections, Statistical Services Branch, Queensland Health
Dr Janet Fairweather, Medical Doctor, Marie Stopes Australia
Dr Leigh Grant, Senior Medical Officer, Obstetrics and Gynaecology, Rockhampton Hospital
Mrs Louise Griffiths, Registered Midwife/Nurse, Maternal Fetal Medicine, Royal Brisbane and Women's
Hospital
Dr Carmon Guy, Senior Medical Officer, Cooktown Hospital
Ms Helen Hicks, Registered Midwife, Maternity Services, Caboolture Hospital
Mrs Debra Hudson, Registered Midwife, Pregnancy Loss Coordinator, Cairns Hospital
Dr Jill Hunady, Regional Medical Officer, True Relationships and Reproductive Health
Mrs Louise Johnston, Clinical Midwifery Consultant (Acting), Women’s and Newborn Services, Royal
Brisbane and Women's Hospital
Dr Shveta Kapoor, Obstetrician Gynaecologist, Ipswich Hospital
Mrs Linda Keidge, Senior Social Worker, Maternity and Paediatrics, Bundaberg Hospital

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This guideline has been developed for WA Health practice setting only. Clinical content is intended to guide clinical practice and does not replace clinical judgement. Modification will occur according to
internal audit processes and literature review. The rationale for the variation from the guideline must be documented in the clinical record.
Ms Daile Kelleher, Manager, Children by Choice
Mrs Melanie McKenzie, Consumer Representative, Harrison's Little Wings
Dr Catriona Melville, Deputy Medical Director, Marie Stopes Australia
Dr Rebecca Mitchell, Senior Obstetrics and Gynaecology Registrar, Cairns Hospital
Mrs Angela Pearson, Senior Social Worker, Princess Alexandra Hospital
Dr Scott Petersen, Staff Specialist, Maternal Fetal Medicine, Mater Mothers' Hospital
Ms Jacqueline Plazina, Clinical Nurse, NICU/NeoRSQ, Royal Brisbane and Women's Hospital
Ms Elizabeth Power, Clinical Nurse Consultant, Sexual Health Cairns
Mrs Catherine Rawlinson, Service Development Leader, Centre for Perinatal and Infant Mental Health
Dr Jane Reeves, Staff Specialist, Obstetrics and Gynaecology, Sunshine Coast University Hospital
Dr Alan Richardson, Director of Medical Services, Roma Hospital
Dr Susan Roberts, Psychiatrist, Perinatal Mental Health, Gold Coast University Hospital
Mrs Christine Roomberg, Registered Nurse/Midwife, Marie Stopes Australia
Dr Shannyn Rosser, Maternal Fetal Medicine Fellow (non-accredited), Royal Brisbane and Women's
Hospital
Mrs Mary-Ellen Russelhuber, Registered Midwife, Maternity Unit, Caboolture Hospital
Mrs Sharon Stokell, Business Manager, True Relationships and Reproductive Health
Mrs Rhonda Taylor, Clinical Midwifery Consultant, Birth Suite, The Townsville Hospital
Ms Siân Tooker, Senior Counsellor, Children by Choice

Queensland Clinical Guidelines Team

Associate Professor Rebecca Kimble, Director
Ms Jacinta Lee, Manager
Ms Stephanie Sutherns, Clinical Nurse Consultant
Ms Cara Cox, Clinical Nurse Consultant
Ms Emily Holmes, Clinical Nurse Consultant
Dr Brent Knack, Program Officer

Funding
This Queensland Clinical Gguideline was funded by Queensland Health, Healthcare Improvement Unit.

Acknowledgements – Western Australia

The Western Australian, Department of Health gratefully acknowledges the contribution of Women’s and
Newborn Health Service clinicians and other stakeholders who participated to adapt the Queensland
Clinical Guidelines to the Western Australian context.
Many thanks to Queensland Health for providing their clinical guidelines as a foundation to build the
Western Australian Clinical Guidelines.

The Western Australian, Department of Health thanks the Office of the Chief Health Officer for their
support and collaboration in updating the INTERIM WA Guidelines and preparing for the online
consultation.

64
PRINT WARNING – Content is continually being revised. ALWAYS refer to the electronic copy for the latest version. Users must ensure that any printed copies of this document are of the latest version.
This guideline has been developed for WA Health practice setting only. Clinical content is intended to guide clinical practice and does not replace clinical judgement. Modification will occur according to
internal audit processes and literature review. The rationale for the variation from the guideline must be documented in the clinical record.
Abortion Legislation Reform Steering Committee
A/Executive Director, Women and Newborn Health Service
Medical Co-Director, Women’s Health, Genetics, Mental Health
Nurse Co-Director, Women’s Health, Genetics, Mental Health
Director Midwifery & Nursing
Consultant, Obstetrics and Gynaecology
Nurse, Midwife Co-Director, Obstetrics and Gynaecology
Executive Director, Office of the Chief Executive, NMHS
Director, Clinical Planning, NMHS
Manager, Women’s Health Strategy and Programs
Executive Director Procurement, Infrastructure and Contract Management
Director of Clinical Services
Public Relations Coordinator
Project Coordinator, SCGH, NMHS
Policy & Project Officer, Women’s Health Strategy & Programs

Cultural Consideration Statement development

The Western Australian, Department of Health gratefully acknowledge the contribution of the following for the
development of the cultural considerations statement for this guideline version:

Appendix B - Aboriginal Clients: Cultural Considerations

Manager, Aboriginal Health, WA Country Health Service (WACHS)
Consultant Service Planning and Development, Aboriginal Health, WACHS
Director, Aboriginal Health Strategy, South Metropolitan Health Service
A/Director, Aboriginal Health, NMHS
Manager, Aboriginal Health, NMHS
Area Director, Aboriginal Health, Royal Perth Hospital, East Metropolitan Health Service (EMHS)
AACCT Program Coordinator, Community and Population Services, EMHS
Aboriginal Health Officer, Maternity, EMHS
Aboriginal Liaison Grandmother, AHS Aboriginal Officers, Maternity, EMHS
Aboriginal Health Liaison Officer, EMHS

Appendix C - Culturally Diverse Clients: Cultural Considerations

Ethnic Communities Council of Western Australia Inc. (ECCWA) Chief Executive Officer (outgoing and
current)
ECCWA Board members

65
PRINT WARNING – Content is continually being revised. ALWAYS refer to the electronic copy for the latest version. Users must ensure that any printed copies of this document are of the latest version.
This guideline has been developed for WA Health practice setting only. Clinical content is intended to guide clinical practice and does not replace clinical judgement. Modification will occur according to
internal audit processes and literature review. The rationale for the variation from the guideline must be documented in the clinical record.
Appendix F: References

1
Public Health Act 2016 (WA). WALW - Public Health Act 2016 - Home Page (legislation.wa.gov.au) [cited 2024
March 19].
2
Abortion Legislation Reform Act 2023 (WA) WALW - Abortion Legislation Reform Act 2023 - Home Page [cited
2024 March 19].
3
Public Health Act 2016 (WA), Part 12C. WALW - Public Health Act 2016 - Home Page (legislation.wa.gov.au)
[cited 2024 March 19].
4
Public Health Act 2016 (WA). WALW - Public Health Act 2016 - Home Page (legislation.wa.gov.au) [cited 2024
March 19].
5
Medicines and Poisons Act 2014 (WA), Section 202MD. WALW - Medicines and Poisons Act 2014 - Home
Page (legislation.wa.gov.au) [cited 2024 March 19].
6
Medicines and Poisons Act 2014 (WA) WALW - Medicines and Poisons Act 2014 - Home Page
(legislation.wa.gov.au) [cited 2024 March 19].
7
Medicines and Poisons Act 2014 (WA) WALW - Medicines and Poisons Act 2014 - Home Page
(legislation.wa.gov.au) [cited 2024 March 19].
8
Public Health Act 2016 (WA). WALW - Public Health Act 2016 - Home Page (legislation.wa.gov.au)
[cited 2024 March 19].
9
Medicines and Poisons Act 2014 (WA) WALW - Medicines and Poisons Act 2014 - Home Page
(legislation.wa.gov.au) [cited 2024 March 19].
10
Medicines and Poisons Act 2014 (WA) WALW - Medicines and Poisons Act 2014 - Home Page
(legislation.wa.gov.au) [cited 2024 March 19].

Health Practitioner Regulation National Law (WA) Act 2010 WALW - Health Practitioner Regulation
11

National Law (WA) Act 2010 - Home Page (legislation.wa.gov.au) [cited 2024 March 19].
12
Public Health Act 2016 (WA), Section 202MH (1). WALW - Public Health Act 2016 - Home Page
(legislation.wa.gov.au) [cited 2024 March 19].
13
Public Health Act 2016 (WA), Part 12C, s.202ME. WALW - Public Health Act 2016 - Home Page
(legislation.wa.gov.au) [cited 2024 March 19]..
14
Public Health Act 2016 (WA). WALW - Public Health Act 2016 - Home Page (legislation.wa.gov.au) [cited
2024 March 19]..
15
Public Health Act 2016 (WA). WALW - Public Health Act 2016 - Home Page (legislation.wa.gov.au) [cited
2024 March 19]..

Health Practitioner Regulation National Law (WA) Act 2010 WALW - Health Practitioner Regulation
16

National Law (WA) Act 2010 - Home Page (legislation.wa.gov.au) [cited 2024 March 19].

66
PRINT WARNING – Content is continually being revised. ALWAYS refer to the electronic copy for the latest version. Users must ensure that any printed copies of this document are of the latest version.
This guideline has been developed for WA Health practice setting only. Clinical content is intended to guide clinical practice and does not replace clinical judgement. Modification will occur according to
internal audit processes and literature review. The rationale for the variation from the guideline must be documented in the clinical record.
17
Health and Disability Services (Complaints) Act 1995 (WA). WALW - Health and Disability Services
(Complaints) Act 1995 - Home Page (legislation.wa.gov.au) [cited 2024 March 19].
18
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(2022) eDoc---CO---PATS-Guidelines---Update-2022.pdf (health.wa.gov.au) [cited 2024 March 19].
19
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framework. Australian Institute of Health and Welfare. Current as at 07/07/2023. Accessed on 04/10/2024.
Source: https://www.aihw.gov.au/reports/indigenous-australians/cultural-safety-health-care-
framework/contents/summary
20
Royal College of Obstetricians and Gynaecologists. Best practice in comprehensive abortion care. Best
Practice Paper No. 2. [Internet]. June 2015. Available from: www.rcog.org.uk [cited 2024 March 19]
21
Public Health Act 2016 (WA). WALW - Public Health Act 2016 - Home Page (legislation.wa.gov.au) [cited
2024 March 19].

Royal College of Obstetricians and Gynaecologists. Clinical Guideline for Abortion Care 2023 Royal College of
22

Obstetricians and Gynaecologists. [cited 2024 March 19].

23
Public Health Act 2016 (WA). WALW - Public Health Act 2016 - Home Page (legislation.wa.gov.au) [cited
2024 March 19]..

State of Western Australia, Consent to Treatment Policy Department of Health (2023) Policy Framework
24

Mandatory Policy Template (health.wa.gov.au) [cited 2024 March 19].

25
Guardianship and Administration Act 1990 (WA) WALW - Guardianship and Administration Act 1990 - Home
Page (legislation.wa.gov.au) [cited 2024 March 19].
26
Guardianship and Administration Act 1990 (WA) WALW - Guardianship and Administration Act 1990 - Home
Page (legislation.wa.gov.au) [cited 2024 March 19].
27
Therapeutic Goods Administration. Australian Product Information - MS-2 Step (mifepristone and
misoprostol). [Internet]. 2023 pdf (tga.gov.au) [cited 2024 March 19].

Secretary of the Department of Health and Community Services v JWB and SMB (Marion’s Case) (1992) 172
28

CLR 218. Available from: www.austlii.edu.au [cited 2024 March 19].

Gillick v West Norfolk & Wisbech Area Health Authority & Department of Health and Social Security [1986]
29

AC112. www.pubmed.ncbi.nlm.nih.gov [cited 2024 March 19].

30
Public Health Act 2016 (WA). WALW - Public Health Act 2016 - Home Page (legislation.wa.gov.au) [cited
2024 March 19]..

Children and Community Services Act 2004 (WA) WALW - Children and Community Services Act 2004 -
31

Home Page (legislation.wa.gov.au) [cited 2024 March 19].

Children and Community Services Act 2004 (WA) WALW - Children and Community Services Act 2004 -
32

Home Page (legislation.wa.gov.au) [cited 2024 March 19].

67
PRINT WARNING – Content is continually being revised. ALWAYS refer to the electronic copy for the latest version. Users must ensure that any printed copies of this document are of the latest version.
This guideline has been developed for WA Health practice setting only. Clinical content is intended to guide clinical practice and does not replace clinical judgement. Modification will occur according to
internal audit processes and literature review. The rationale for the variation from the guideline must be documented in the clinical record.
Children and Community Services Act 2004 (WA) WALW - Children and Community Services Act 2004 -
33

Home Page (legislation.wa.gov.au) [cited 2024 March 19].

Children and Community Services Act 2004 (WA) WALW - Children and Community Services Act 2004 -
34

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Department of Communities (2024) Mandatory Reporting Guide: Western Australia. May 2024. [cited 2024,
35

October 21]. Available from: mandatory_reporting_guide_western_australia.pdf (www.wa.gov.au)

Children and Community Services Act 2004 (WA) WALW - Children and Community Services Act 2004 -
36

Home Page (legislation.wa.gov.au) [cited 2024 March 19].

37
Royal College of Obstetricians and Gynaecologists. Best practice in comprehensive abortion care. Best
Practice Paper No. 2. [Internet]. June 2015. Available from: www.rcog.org.uk [cited 2024 March 19]
38
Royal College of Obstetricians and Gynaecologists. Best practice in comprehensive abortion care. Best
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41
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42
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March 19].
44
National Abortion Federation (NAF). Clinical policy guidelines for abortion care. [Internet]. 2022. Available
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45
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46

Rh(D) immunoglobulin (Anti-D) in obstetrics. [Internet]. 2023 Available from: www.ranzcog.edu.au [cited 2024
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47
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Australian Government - Australian STI Management Guidelines For Use In Primary Care [Internet].
48

Developed by ASHM. Updated December 2021. Available from: STI Guidelines Australia | Australian STI
Guidelines website [cited 2024 March 19].

68
PRINT WARNING – Content is continually being revised. ALWAYS refer to the electronic copy for the latest version. Users must ensure that any printed copies of this document are of the latest version.
This guideline has been developed for WA Health practice setting only. Clinical content is intended to guide clinical practice and does not replace clinical judgement. Modification will occur according to
internal audit processes and literature review. The rationale for the variation from the guideline must be documented in the clinical record.
49
Royal College of Nursing. Termination of pregnancy: an RCN nursing framework. [Internet]. 2024. Available
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BY-NC-SA 3.0 IGO. Clinical practice handbook for quality abortion care (who.int) [cited 2024 March 19].

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54

BY-NC-SA 3.0 IGO. Clinical practice handbook for quality abortion care (who.int) [cited 2024 March 19].
55
The Royal Australian and New Zealand College of Obstetricians and Gynaecologists. Long acting
reversible contraception. [Internet]. 2017 [cited 2019 May 1]. Available from: www.ranzcog.edu.au [cited
2024 March 19]

Clinical practice handbook for quality abortion care. Geneva: World Health Organization; 2023. Licence: CC
56

BY-NC-SA 3.0 IGO. Clinical practice handbook for quality abortion care (who.int) [cited 2024 March 19].
57
Births Deaths and Marriages Registration Act 1998 (WA) WALW - Births, Deaths and Marriages Registration
Act 1998 - Home Page (legislation.wa.gov.au) [cited 2024 March 19]
58
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(ranzcog.edu.au) [cited 2024 March 19].
59
Rocca CH, Samari G, Foster DG, Gould H, Kimport K. Emotions and decision rightness over five years
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National Collaborating Centre for Mental Health. Induced abortion and mental health. A systematic review
of the mental health outcomes of induced abortion, including their prevalence and associated factors.

69
PRINT WARNING – Content is continually being revised. ALWAYS refer to the electronic copy for the latest version. Users must ensure that any printed copies of this document are of the latest version.
This guideline has been developed for WA Health practice setting only. Clinical content is intended to guide clinical practice and does not replace clinical judgement. Modification will occur according to
internal audit processes and literature review. The rationale for the variation from the guideline must be documented in the clinical record.
London: Academy of Medical Royal Colleges. [Internet]. 2011 Available from: www.aomrc.org.uk [cited 2024
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70
PRINT WARNING – Content is continually being revised. ALWAYS refer to the electronic copy for the latest version. Users must ensure that any printed copies of this document are of the latest version.
This guideline has been developed for WA Health practice setting only. Clinical content is intended to guide clinical practice and does not replace clinical judgement. Modification will occur according to
internal audit processes and literature review. The rationale for the variation from the guideline must be documented in the clinical record.
www.pubmed.ncbi.nlm.nih.gov [cited 2024 March 19].

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71
PRINT WARNING – Content is continually being revised. ALWAYS refer to the electronic copy for the latest version. Users must ensure that any printed copies of this document are of the latest version.
This guideline has been developed for WA Health practice setting only. Clinical content is intended to guide clinical practice and does not replace clinical judgement. Modification will occur according to
internal audit processes and literature review. The rationale for the variation from the guideline must be documented in the clinical record.
[Internet]. 2022 Available from: www.rcog.org.uk [cited 2024 March 19].
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72
PRINT WARNING – Content is continually being revised. ALWAYS refer to the electronic copy for the latest version. Users must ensure that any printed copies of this document are of the latest version.
This guideline has been developed for WA Health practice setting only. Clinical content is intended to guide clinical practice and does not replace clinical judgement. Modification will occur according to
internal audit processes and literature review. The rationale for the variation from the guideline must be documented in the clinical record.
106
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PRINT WARNING – Content is continually being revised. ALWAYS refer to the electronic copy for the latest version. Users must ensure that any printed copies of this document are of the latest version.
This guideline has been developed for WA Health practice setting only. Clinical content is intended to guide clinical practice and does not replace clinical judgement. Modification will occur according to
internal audit processes and literature review. The rationale for the variation from the guideline must be documented in the clinical record.
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74
PRINT WARNING – Content is continually being revised. ALWAYS refer to the electronic copy for the latest version. Users must ensure that any printed copies of this document are of the latest version.
This guideline has been developed for WA Health practice setting only. Clinical content is intended to guide clinical practice and does not replace clinical judgement. Modification will occur according to
internal audit processes and literature review. The rationale for the variation from the guideline must be documented in the clinical record.
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75
PRINT WARNING – Content is continually being revised. ALWAYS refer to the electronic copy for the latest version. Users must ensure that any printed copies of this document are of the latest version.
This guideline has been developed for WA Health practice setting only. Clinical content is intended to guide clinical practice and does not replace clinical judgement. Modification will occur according to
internal audit processes and literature review. The rationale for the variation from the guideline must be documented in the clinical record.
151
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76
PRINT WARNING – Content is continually being revised. ALWAYS refer to the electronic copy for the latest version. Users must ensure that any printed copies of this document are of the latest version.
This guideline has been developed for WA Health practice setting only. Clinical content is intended to guide clinical practice and does not replace clinical judgement. Modification will occur according to
internal audit processes and literature review. The rationale for the variation from the guideline must be documented in the clinical record.
qualitative interviews on counseling and provision of long-acting reversible contraceptive methods.
Perspectives on Sexual & Reproductive Health 2012;44(2):100-6. www.guttmacher.org [cited 2024 March
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77
PRINT WARNING – Content is continually being revised. ALWAYS refer to the electronic copy for the latest version. Users must ensure that any printed copies of this document are of the latest version.
This guideline has been developed for WA Health practice setting only. Clinical content is intended to guide clinical practice and does not replace clinical judgement. Modification will occur according to
internal audit processes and literature review. The rationale for the variation from the guideline must be documented in the clinical record.
181
State of Western Australia. Statewide Maternity Shared Care Guidelines (2021) North Metropolitan Health
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Fox M C, Krajewski CM. Cervical preparation for second-trimester surgical abortion prior to 20 weeks
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repository.uwa.edu.au/ws/portalfiles/portal/10908691/THESIS_DOCTOR_OF_PHILOSOPHY_THACKRAH_Ros
alie_Dawn_2016.pdf

Arabena K. (2006) Preachers, policies and power: the reproductive health of adolescent Aboriginal and
186

Torres Strait Islander peoples in Australia. Health Promot J Austr 2006; 17: 85-90. Accessed on: 11/09/2024.
187
Rhonda Marriott, Tracy Reibel, Juli Coffin, Janinne Gliddon, Denese Griffin, Melanie Robinson, Ann-Marie
Eades, Jade Maddox (2019) “Our culture, how it is to be us” — Listening to Aboriginal women about on
Country urban birthing. Women and Birth Journal, Volume 32, Issue 5, October 2019, Pages 391-403.
Accessed on: 11/09/2024. Source:
https://www.sciencedirect.com/science/article/abs/pii/S1871519219302549?via%3Dihub
188
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Accessed on: 11/09/2024. Source: https://www.apsc.gov.au/working-aps/diversity-and-inclusion/diversity-
inclusion-news/cultural-load-its-real-thing

Nicole Tujague and Kelleigh Ryan (2023) Cultural Safety in Trauma-Informed Practice from a First Nations
189

Perspective. Published by Billabongs of Knowledge.

190
Queensland Government (2023) Respect for cultural protocols and practices, Women’s business and men’s
business. Accessed on: 11/09/2024. Source: https://cspm.csyw.qld.gov.au/practice-kits/safe-care-and-
connection/working-with-aboriginal-and-torres-strait-islander/seeing-and-understanding/respect-for-cultural-
protocols-and-practices#Women_s_business_and_men_s_business

Patricia Dudgeon and Abigail Bray (2019) Indigenous Relationality: Women, Kinship and the Law.
191

Genealogy. Accessed on: 30/09/2024. Source: https://www.mdpi.com/2313-5778/3/2/23

Indigenous Allied Health Australia (2019) Policy Position Statement - Cultural Safety through responsive
192

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193
Carmen Parter, Donna Murray, Romalie Mekak, Karl Briscoe, Richard Weston and Janine Mohamed (2024)

78
PRINT WARNING – Content is continually being revised. ALWAYS refer to the electronic copy for the latest version. Users must ensure that any printed copies of this document are of the latest version.
This guideline has been developed for WA Health practice setting only. Clinical content is intended to guide clinical practice and does not replace clinical judgement. Modification will occur according to
internal audit processes and literature review. The rationale for the variation from the guideline must be documented in the clinical record.
Implementing the cultural determinants of health: our knowledges and cultures in a health system that is not free
of racism. Accessed on: 11/09/2024. Source: https://onlinelibrary.wiley.com/doi/10.5694/mja2.52352
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regulation.aspx
195
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Ahpra/Aboriginal-and-Torres-Strait-Islander-Health-Strategy/Employment-strategy.aspx

Australian Commission on Safety and Quality in Health Care (2017) National Safety and Quality Health
197

Service Standards User Guide for Aboriginal and Torres Strait Islander Health. Accessed on 11/09/2024.
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WA Health (2015) WA Aboriginal Health and Wellbeing Framework 2015-2030. Accessed on 11/09/2024.
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Closing the Gap (2020) National Agreement on Closing the Gap July 2020. Accessed on 11/09/2024.
199

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Closing the Gap (2020) 6. Priority Reform Areas for Joint National Action. Accessed on: 11/09/2024.
Source: https://www.closingthegap.gov.au/national-agreement/national-agreement-closing-the-gap/6-priority-
reform-areas
201
WA Government (2021) Aboriginal Empowerment Strategy – Western Australia 2021-2029. Accessed on
11/09/2024. Source: https://www.wa.gov.au/government/publications/aboriginal-empowerment-strategy-
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Department of Health (2021) Aboriginal Health Impact Statement and Declaration Policy. Accessed on
11/09/2024. Source: https://www.health.wa.gov.au/About-us/Policy-frameworks/Clinical-Services-Planning-and-
Programs/Mandatory-requirements/Aboriginal-Health/Aboriginal-Health-Impact-Statement-and-Declaration-
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Department of Health Multicultural Health. Accessed on 11/09/2024. Source:
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Department of Health (2015) Resource toolkit for refugee and migrant women accessing maternity services.
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migrant-women-accessing-maternity-services

79
PRINT WARNING – Content is continually being revised. ALWAYS refer to the electronic copy for the latest version. Users must ensure that any printed copies of this document are of the latest version.
This guideline has been developed for WA Health practice setting only. Clinical content is intended to guide clinical practice and does not replace clinical judgement. Modification will occur according to
internal audit processes and literature review. The rationale for the variation from the guideline must be documented in the clinical record.

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