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Right Decision Service newsletter: October 2024

Welcome to the Right Decision Service (RDS) newsletter for October 2024.

1.Contingency arrangements for RDS outages

Development of the contingency solutions to maximise RDS resilience and minimise risk of future outages is in progress, aiming for completion by Christmas. As a reminder, these contingency arrangements  are:

  • Optimising mobile app build process
  • Mobile app always to be downloadable.
  • Serialising builds to mobile app; separate mobile app build from other editorial and end-user processes
  • Load balancing – provides failover (also enables separation of editorial processes from other processes to improve performance.)

 

In the meantime, a gentle reminder to encourage users to download essential clinical toolkits to their mobile devices so that there is an offline version always available.

 

2. New deployment with improvements.

A new scheduled deployment with minor improvements drawn from support tickets, externally funded projects, information related to outages, and feature requests will take place in early December. Key improvements planned are:

  • Deep-linking to individual toolkits within the RDS mobile app. Each toolkit will now have its own direct URL and QR code, both accessible from the app. These can be used to download the toolkit directly where users already have the RDS app installed. If the user does not yet have the RDS app installed, they will be taken to the app store to install the app and immediately afterwards the toolkit will automatically open and download. Note that this will go live a few days later than the improvements below due to the need to link up the mobile front end to the changes in the content management system.
  • Introducing an Announcement Header field to replace the hardcoded "Announcements and latest updates" text. This will enable users to see at a glance the focus of new announcements.
  • Automated daily emptying of the recycling bin (with a 30 day rolling grace period)  in the content management system. A bug preventing complete emptying of the recycling bin contributed to one of the outages earlier this year.
  • Supporting multiple passcodes (ticket 6079)
  • Expanding accordion section to show location of a search result rather than requiring user coming from a search result to manually open all sections and search again for the term.
  • Displaying first accordion section Content text as a snippet on the search results page as a fallback if default/main content is not provided
  • Displaying the context of each search result in the form of a link to the relevant parent tool/section. This will help users to choose which search result is most likely to be appropriate for their needs.
  • As part of release of the new national benzodiazepine quality prescribing guidance toolkit sponsored by Scottish Government Effective Prescribing and Therapeutics, a digital tool to support creation of benzodiazepine tapering/withdrawal schedules.

We are also seeking approval to use the NHS Scotland logo and title for the RDS app on the app stores to help with audience engagement and clarity around the provenance of RDS.

3. RDS Search, Browse and Archive/Version control enhancements

We are still hopeful that user acceptance testing for at least the Search and browse enhancements can take place before Christmas. Thank you for your patience and understanding in waiting for these improvements. Timescales have been pushed back by old app migration challenges, work to address outages, and most recently implementing the contingency arrangements.

4. Support tickets

We are aware that there continue to be some issues around a number of RDS support tickets, in part due to constraints around visibility for the RDS team of the tickets in the existing  support portal. We are investigating the potential to move to a new support ticket requesting system from early in the new year. We will organise the proposed webinar around support ticket processes once we have confirmed the way forward with the system.

Table formatting

There is a known issue with alterations in formatting of some RDS tables which seems to have arisen as a result of the 17 October deployment. Tactuum is working on a fix and on implementing additional regression testing to prevent this issue recurring.

5. New RDS toolkits

Recently launched toolkits include:

NHS Lothian Infectious Diseases

Scottish Health Technologies Group – Technology Assessment recommendations

NHS Tayside Anaesthetics and Critical Care projects – an innovative toolkit which uses PowerAutomate to manage review and response to proposals for improvement projects.

If you would like to promote one of your new toolkits through this newsletter, please contact ann.wales3@nhs.scot

A number of toolkits are expected to go live before Christmas, including:

  • Focus on dementia
  • Highland Council Getting it Right for Every Child
  • Dumfries and Galloway Adult Support and Protection procedures
  • National Waiting Well toolkit
  • Fertility Scotland National Network
  • NHS Lothian postural care for care homes

6.Sign up to RDS Editors Teams channel

We have had a good response to the recent invitation to sign up to the new Teams channel for RDS editors. This provides a forum for editors to share learning, ideas and questions and we hope to hold regular webinars on topics of interest.  The RDS team is in the process of joining participants to the channel and we’d encourage all editors to take part, using the registration form – available in Providers section of the RDS Learning and Support area.

 

7. Evaluation projects

The RDS team has worked with colleagues in NHS Grampian and the Digital Health & Care Innovation Centre to evaluate the impact of the Prevent the progress of diabetes web and mobile app in a small-scale pilot project. This app provides access to local and national resources and services targeted at people with prediabetes, a history of gestational diabetes, or candidates for remission. After just 8 weeks of using the app, 94% of patients reported increased their knowledge and understanding of diabetes, and 88% said it had increased their confidence and motivation to make lifestyle changes, highlighting specific behaviour changes. The learning from this project is informing development of a service model based on tailored support for patient groups with, high, medium and low digital self-efficacy.

Please contact ann.wales3@nhs.scot if you would like to know more about this project.

  1. Training sessions for new editors (also serve as refresher sessions for existing editors) will take place on the following dates:

  • Friday 29th November 3-4 pm
  • Thursday 5 December 3.30 -4.30 pm

To book a place, please contact Olivia.graham@nhs.scot, providing your name, organisation, job role, and level of experience with RDS editing (none, a little, moderate, extensive.)

 

To invite colleagues to sign up to receive this newsletter, please signpost them to the registration form  - also available in End-user and Provider sections of the RDS Learning and Support area.   If you have any questions about the content of this newsletter, please contact his.decisionsupport@nhs.scot  If you would prefer not to receive future newsletters, please email Olivia.graham@nhs.scot and ask to be removed from the circulation list.

With kind regards

 

Right Decision Service team

Healthcare Improvement Scotland

 

The Right Decision Service:  the national decision support platform for Scotland’s health and care

Website: https://rightdecisions.scot.nhs.uk    Mobile app download:  Apple  Android

 

 

Medical Termination of Pregnancy Protocol (513)

Please report any inaccuracies or issues with this guideline using our online form

< 10 + 0 WEEKS GESTATION

Mifepristone Day

  • Ensure case-notes and appropriate documentation available.
  • Check consent form is signed
  • Check certificate A has 2 signatures.
  • Ensure confirmed intra-uterine pregnancy.
  • Complete paperwork in ICP/electronic record
  • Check the patient is sure of their decision.
  • Administer mifepristone 200mg PO in accordance with drug kardex. Patient may go home thereafter.
  • Advise patient to return to the place of administration if she vomits within 1 hour.
  • Ensure advice is given to the patient regarding pain and/or bleeding she may experience over the following 24-48 hours.
  • Ensure the patient has the ward telephone number.
  • Advise the patient to bring appropriate clothing for admission.

Misoprostol Day
48 hours following mifepristone.

  • Nurse enquires about pain/bleeding/passage of products of conception.
  • Check BP, pulse and temperature.
  • Explain the procedure to the patient.
  • Patient is NOT routinely required to fast.
  • Confirm contraceptive plan, and prescribe/administer as indicated.
  • Misoprostol 800 micrograms PV.
  • Diclofenac 100mg PR as prophylactic analgesia unless contraindicated. (If contra-indicated cocodamol 30/500 PO).
  • Patient to use bed pan throughout procedure to aid identification of POC.
  • If products ARE passed, follow the discharge procedure.

If no POC passed within 6 hours:

  • If POC are not passed within 4 hours administer 400 micrograms of misoprostol sublingually.
  • If no POC passed within one hour, perform speculum examination to ensure POC are not in cervix/vagina.

If POC are not identified following a second dose of misoprostol or during vaginal examination:

  • If pain and bleeding are satisfactory, the patient should be discharged home. The patient should be offered either follow-up scan by appointment at Sandyford after 7-14 days or a pregnancy test after 21 days. If the patient chooses the latter option, the pregnancy test kit should be supplied to the patient on discharge. If she chooses the scan option, then Sandyford contact details should be given so that she can make an appointment.
  • For patients who are <10 + 0 weeks gestation and pass what is thought to be incomplete POC – follow up is scan is NOT required. Advise the patient that bleeding is to be expected, however ensure ward contact details are given so that the patient can contact staff should they be concerned that their bleeding is heavier than anticipated.  

If excessive bleeding occurs before/after POC passed:

  • Perform speculum examination to evacuate clot and remove any POC identified.
  • If bleeding continues contact middle grade or consultant gynaecologist.
  • Fast patient.
  • Site venflon.
  • Check P/BP/T/O2 saturation every 15 minutes/high-flow facial O2 if bleeding continues.
  • Send FBC.
  • Cross-match and check clotting screen if signs of shock.
  • Give misoprostol 400 micrograms sublingually.
  • Give ergometrine 500 micrograms IM unless contra-indicated for the patient. This can be given at the same time as misoprostol, as it will be effective before the misoprostol has its maximum effect.
  • If bleeding persists or there are clinical signs of shock (tachycardia, hypotension), an urgent surgical evacuation should be arranged by medical staff.

DISCHARGE PROCEDURE FOR ALL PATIENTS

  • Record the patient’s BP, pulse and temperature prior to discharge.
  • Contraception must be supplied or a contraceptive plan agreed.
  • Anti-D is NOT required for rhesus negative women.
  • All patients with a multiple pregnancy require a follow-up scan at Sandyford

Scan Post TOP

If scan shows RPOC < 3cm – advise patient to seek referral if increased PV bleeding, pain or offensive PV loss.

If scan shows RPOC > 3cm the patient should be offered surgical evacuation of uterus if clinically indicated i.e. excessive bleeding.

If the patient declines surgical evacuation she may be managed conservatively with anti-biotics (co-amoxiclav 375mg TID for 7 days). A further scan will be required after 7-10 days to ensure RPOC is decreasing in size.

If scan shows a continuing pregnancy the patient should be given the option of MTOP or STOP depending on their gestation.

Protocol for MTOP 10-18 weeks gestation

Mifepristone Day

  • Ensure case-notes and appropriate documentation available.
  • Check consent form is signed
  • Check certificate A has 2 signatures.
  • Ensure confirmed intra-uterine pregnancy.
  • Complete paperwork in the ICP/electronic record.
  • Check the patient is sure of their decision.
  • Administer mifepristone 200mg PO in accordance with drug kardex. Patient may go home thereafter.
  • Advise patient to return to the place of administration if they vomit within 1 hour.
  • Ensure advice is given to the patient regarding pain and/or bleeding they may experience over the following 24-48 hours.
  • Ensure the patient has the ward telephone number.
  • Advise the patient to bring appropriate clothing for admission.

Misoprostol Day
48 hours following mifepristone.

  • Nurse enquires about pain/bleeding/passage of products of conception.
  • Check BP, pulse and temperature.
  • Explain the procedure to the patient.
  • Patient is NOT routinely required to fast.
  • Confirm contraceptive plan, and prescribe/administer as indicated.
  • Administer Misoprostol 800 micrograms PV.
  • Diclofenac 100mg PR as prophylactic analgesia unless contraindicated. (If contra-indicated cocodamol 30/500 PO).
  • After 3 hours administer 400 micrograms of misoprostol sublingually and repeat at 3 hourly intervals until abortion occurs.
  • Analgesia and anti-emetics should be administered as required.
  • Patient to use bedpan throughout procedure to aid identification of POC.
  • Following the delivery of foetus either with or without the placenta, syntometrine (ergometrine 500 micrograms with oxytocin 5 units) 1ml IM should be administered.
  • If the placenta is not passed within the hour of syntometrine being administered, the patient should be examined vaginally and placenta retrieved if possible.
  • If the placenta is not retrieved, site venflon, fast patient, and arrange theatre. Check FBC/coagulation screen if heavy bleeding.
  • Whilst awaiting theatre, administer misoprostol 400 micrograms sublingually. This should be repeated after a further 3 hours if still awaiting theatre.
  • Heavy PV bleeding following passage of placenta requires medical review to assess need for surgical evacuation of uterus. See “management of excessive bleeding” in <10 + 0 week section of guideline above.

Failure to Abort After 24 hours of Misoprostol 10 - 13 + 0 weeks

Surgical evacuation should be offered to patient.
If surgery declined/contraindicated follow guidance below.

Failure to Abort After 24 hours of Misoprostol > 13 + 0 weeks

  • Continue to give misoprostol 400 micrograms sublingually
  • 4 hourly BP/P/T. Commence NEWS chart.
  • PV assessment should be carried out by experienced medical staff 24 hours from commencing misoprostol.
  • If abortion has not occurred after 48 hours of misoprostol, further management must be discussed with a consultant gynaecologist.
  • Management will depend on the condition of the individual patient, pyrexia and gestation.
  • Ultrasound scan should be performed to exclude abdominal pregnancy/uterine rupture.
  • Consider day 3 of misoprostol if membranes intact.

DISCHARGE PROCEDURE FOR ALL PATIENTS

  • Record the patient’s BP, pulse and temperature prior to discharge.
  • Contraception must be supplied or a contraceptive plan agreed.
  • Anti-D prophylaxis MUST be given to ALL rhesus negative women over 10 weeks.
  • All patients with a multiple pregnancy require a follow-up scan at Sandyford

Editorial Information

Last reviewed: 01/12/2020

Next review date: 31/12/2025

Author(s): Nikki Harvey.

Version: 4 (Revised December 2020)

Approved By: Gynaecology Clinical Governance Group

Document Id: 513