Acute Health Division
Department of Human Services
AVictorian Government Department, Australia 

Medical Practitioners Board of Victoria

Report on late term terminations of pregnancy
April 1998

FINDINGS

 

1. Current practice in Victoria in major hospitals

The only indications for which terminations of pregnancy beyond 20 weeks are being performed in Victoria at the present time appear to be for grave fetal abnormality or life threatening maternal illness. All such terminations are performed at tertiary referral centres - namely the Royal Women’s Hospital and Monash Medical Centre.

Although formal investigations by the Board did not indicate that late terminations of pregnancy for psychosocial reasons were occurring in Victoria, it was reported that hospital staff receive requests for termination on these grounds after 20 weeks gestation.

There is uncorroborated hearsay evidence that such terminations do occur in the private sector. The Board attempted to find confirmatory evidence but there was no such evidence forthcoming. Therefore, the Board was not able to form an opinion on the frequency of such terminations.

The two major obstetric hospitals that are performing late terminations are doing so openly. They are complying with the legal requirements and there is clinical peer review. Both hospitals have integrated and comprehensive multidisciplinary support services.

 

1.1 Royal Women’s Hospital

In the twelve months to October 1997, the Royal Women’s hospital reported that they had performed 32 terminations of pregnancy that were more than 20 weeks gestation. All of these were performed because of serious fetal abnormality. This rate is comparable with recent years and is not believed to be changing dramatically.

Other possible reasons for pregnancy termination after 20 weeks would include life threatening maternal illness. In such instances, assessment would involve appropriate medical specialists and they are reported to be extremely rare in the practice of the Royal Women’s Hospital.

There are obstetric indications for induction of labour and these include premature rupture of the membranes with infection, severe antepartum haemorrhage and severe pre-eclampsia. These may occasionally occur after 20 weeks gestation and prior to fetal viability.

In determining whether to perform a late termination of pregnancy, the circumstances of each case are considered. The decision is based on the effect on the health of the mother and a multi-disciplinary team works together closely and is dedicated to her care. The team includes an obstetrician, ultrasonographer, geneticists, nursing staff and counsellors. The final decision concerning termination and the method of termination rests with the mother.

The Genetic Counselling Service is directly involved in the care of women who seek late terminations for fetal abnormality at the Royal Women’s Hospital. The service provides:

• counselling and support
• referral to other specialists including medical geneticists, paediatric cardiologists, paediatric surgeons, ultrasonographers, perinatologists and paediatricians for the provision of information and counselling about potential outcomes, including continuation of the pregnancy;
• bereavement care
• Follow up appointments and support.

The Royal Women’s Hospital has employed a Reproductive Loss Coordinator to assist in ensuring appropriate care and follow-up of women who have experienced fetal loss, including that due to fetal abnormality.

A death certificate is completed for all cases of fetal death after 20 weeks in accordance with the law. All such cases are reviewed at the monthly Perinatal Mortality Meeting. The circumstances and management of each case are thus subject to peer review.

At the Royal Women’s Hospital, the majority of terminations over 20 weeks gestation are performed by induction of labour with prostaglandin (misoprostol). A small number are performed as a surgical procedure with dilatation and evacuation under anaesthesia.

It is acknowledged that no ideal method has been determined and both procedures have a place. Factors that are taken into account include the woman’s preference and the pathological requirements for accurate diagnosis.

Following the termination, the fetus and the tissues are carefully handled and retained. The parents are encouraged to decide about disposal and this may include burial and religious ceremony. Memory folders are created and may include photographs and foot and hand prints.

 

1.2 Monash Medical Centre

It is estimated that there are approximately 50 terminations for fetal abnormality performed annually at Monash Medical Centre.

Terminations after 20 weeks are performed almost exclusively for fetal abnormalities. Terminations for psychosocial indications are performed up to 18 weeks although in exceptional circumstances may be performed up to 20 weeks.

There is approximately one request for a psychosocial termination every three to four weeks beyond 20 weeks. In such instances, the patient is informed that it is too late and is offered further care of the pregnancy.

At Monash Medical Centre, there is no upper limit of gestation when a termination may be performed for a lethal abnormality. The upper limit of viability is considered for lesser abnormalities.

The parents are fully advised during all stages of investigation and in reaching the decision whether to terminate a pregnancy. The mother has the major say in the decision.

With regard to where to draw the line in embarking on termination, the severity of the abnormality is considered and a consensus is reached between the parents, the treating doctor, hospital staff, the institution and the general community.

As at the RWH, the methods of termination are by prostaglandin induction or by dilatation and evacuation.

After delivery by induction, the parents are able to hold their infant. On occasion, the baby may survive a few moments. Parents are able to name the baby, to make burial arrangements and to keep momentos.

Counselling is offered to all women undergoing termination in the second trimester for psychosocial reasons (14 - 19 weeks) but the offer is seldom accepted. Counselling is provided for all women who have termination for fetal abnormality and is provided by members of the clinical team. This may include medical staff, nurse coordinator, geneticist or counsellor.

As at the Royal Women’s Hospital, Monash Medical Centre has an established and well-coordinated team approach with a focus on the psychological as well as physical care of the mother. The parents are treated with sensitivity and management is in accordance with their wishes.

 

1.3 Mercy Hospital for Women

In the written submission by the Clinical Director of Obstetrics and Gynaecology from the Mercy Hospital for Women, the view expressed is that "modern management demands, and the law expects, that the babies be given every opportunity to survive." There is no comment regarding the practice at the Mercy in situations of gross or lethal fetalospital for WomenhhhHoo abnormality or life threatening illness in the mother.

 

 

2. Reasons for late termination

Later terminations in Victoria are largely confined to fetal abnormalities. There are a very small number of such terminations being performed for maternal illness.

Some of the situations in which a late term termination of pregnancy may be requested include:

• Late maternal presentation;
• Organisational delays resulting in post 20 week investigation;
• Difficulties in the interpretation of ultrasound abnormalities by staff and the repeat of such tests at a later stage of the pregnancy;
• Patients having a change of mind regarding prenatal diagnosis;
• Abnormalities coincidentally identified during a post 20 week ultrasound examination carried out for other reasons;
• Some conditions such a hydrocephaly and some skeletal dysplasias may not be detectable until after 20 weeks;
• Intra-uterine infection may sometimes be only confirmed post 20 weeks and
• Conditions recognised prior to 20 weeks may subsequently worsen. For example, renal abnormalities.

 

3. Termination when there is fetal abnormality

Although a number of screening tests are being performed as a matter of routine, a number of the Board’s submissions expressed concerns regarding the use of such tests. This was especially in relation to preceding counseling and the implications of a positive (or a false positive) result as well as in the timing of testing that may result in mid trimester abortions being performed at a later stage in the pregnancy.

A number of submissions to the Board emphasised the importance of appropriate and timely screening for fetal abnormality by well trained and highly experienced personnel. A small number of late term terminations may be avoided by earlier screening or by the early referral to more experienced medical staff when an abnormality is detected. There remain a small number of terminations for fetal abnormality that are performed after 20 weeks because of lack of access to specialist investigation.

The working party established that there is a range of fetal abnormality that is detectable and for which a later termination may be sought. Within Victoria, the majority of late term terminations that are performed are for severe fetal abnormalities. These include:

• Conditions that are incompatible with life, such as anencephaly or renal agenesis;
• Gross fetal abnormalities including some chromosomal abnormalities, severe congenital abnormalities that would require extensive surgery (eg cardiac) or gross physical deformities;

There are also circumstances where a termination may be requested on the grounds of fetal abnormality of a lesser degree but which may cause psychological harm to the mother. These situations are more difficult to deal with as the fetal condition may be treatable, at least in part, by surgery. Facial deformities such as cleft palate and limb deformities may fall into this category.

In assisting parents to make well-informed decision, the centres that perform late term terminations beyond 20 weeks provide them with high quality information regarding the fetal abnormality and its consequences. There is thus an important role for neonatologists, paediatricians, geneticists and other medical specialists.

 

4. Termination for severe illness in the mother

Of the late term terminations of pregnancy that are being performed in Victoria, only a very small number are for severe illness in the mother. Some of these conditions are complications of the pregnancy itself while others relate to primary maternal conditions that may deteriorate as a result of the pregnancy.

4.1 Complications of pregnancy

• Severe pre-eclampsia before fetal viability where progression of the pregnancy to the stage of viability may put the mother at significant risk;
• Premature rupture of the membranes with infection prior to fetal viability;
• Severe antepartum haemorrhage prior to fetal viability.

 

4.2 Primary maternal conditions

• Certain maternal conditions may be lethal where the pregnancy is permitted to continue. Examples include pulmonary hypertension and cyanotic heart disease;
• Where the mother is suffering from end stage malignancy;
• The majority of terminations for psychosocial reasons occur in the first and early second trimester. It would be exceedingly rare that a later termination is performed for severe psychological illness in the mother.

 

5. Termination for conditions of the fetus that would cause severe illness to the mother

There are a very small number of fetal conditions where the progression of the pregnancy may lead to significant maternal morbidity or mortality. These conditions are rare.

• Hydrops faetalis, immune and non immune - The former, now rare with the widespread usage of Rh(D) Immunoglobulin may result in "maternal syndrome" which may lead to significant maternal mortality and morbidity and
• Rare instances where a fetus is present in association with a hydatitiform mole or choriocarcinoma may result in significant morbidity or death of the mother.

 

6. Termination for psychological or social health of the mother

The Board’s formal investigations did not confirm that late terminations are being performed for psychosocial reasons. However, it was reported that hospital staff received inquiries regarding such termination and there was unconfirmed advice that such terminations occur in the private sector.

The Royal Women’s Hospital and Monash Medical Centre confirmed that terminations of pregnancy after 20 weeks are being performed for the indications of severe or lethal fetal abnormality or severe maternal illness. Such terminations are not offered for psychosocial reasons at these hospitals.

 

7. The methods used for termination

There are two methods that are used in Victoria to terminate pregnancies beyond 20 weeks. These are:

a. Induction of labour with prostaglandin (misoprostol)

Prostaglandin is administered vaginally and orally at intervals until labour is induced.

This procedure usually occurs in the delivery suite.

In some instances, there may be an intra-uterine, fetal intra-cardiac injection of potassium chloride to ensure the delivery of a dead baby, thus reducing the distress of staff and minimising the possibility that the fetus will experience pain. This is performed following the written consent of the parents.

b. Dilatation and Evacuation following cervical ripening with prostaglandin misoprostol

Prostaglandin is administered vaginally and orally and then the procedure is performed in the operating theatre, usually under general anaesthesia. The patient is usually discharged home later that day.

It is believed that each of the above procedures has a role to play in specific circumstances. Factors that are taken into consideration in the selection of the method include:

• The mother’s preference including:
• does the mother have a wish to see and hold the baby;
• does the mother want to experience labour;
• does she want to be managed as an inpatient or outpatient
• does she want to create a memory folder and if so, does she want photographs. Footprints and limited photographs (foot or hand) may also be obtained with the surgical method.
• The need for pathological identification - In most terminations for fetal abnormalities, the diagnosis is already known. With some abnormalities, an intact fetus is preferred to clarify the problem and perhaps to quantify the risk of recurrence, thus assisting future genetic counseling. This is especially the case in relation to skeletal dysplasias and some babies with multiple malformations.
• The specific circumstances of the pregnancy. For example, some fetal anomalies may be associated with reduced liquor volume making induction of labour inappropriate.

Both techniques are considered safe but there is evidence that Dilatation and Evacuation may be safer than induction of labour.

 

8 The optimal management of the termination

There is no single protocol that defines the optimal management of a late termination of pregnancy. The individual circumstances of each pregnancy and the wishes of the parents are prime considerations. However, there are a number of key elements to consider:

8.1 Pre diagnosis

The use of screening and confirmatory tests

There is a number of screening tests that are performed in Victoria as a matter of routine. As with any test, the patient should be given information about the test, including the implications of a positive result.

Testing should be timely and should be conducted by experienced staff. Where there is some doubt about diagnosis, early referral is indicated to allow for a more definitive diagnosis and early management.

8.2 Post diagnosis

Counselling

The process whereby information is provided to parents is a fundamental aspect of the management of the termination. The object of the provision of information is to allow the parents to make an informed decision about the management of the pregnancy. A termination of the pregnancy is not necessarily the optimal outcome.

The counselling process is most effectively conducted in an environment where a multi-disciplinary team of health professionals provides a coordinated, supportive and non-judgmental environment for the parents, allowing them to make their decision. Where it is feasible, the involvement of both parents is to be preferred although ultimately, all centres take the wishes of the mother as a priority.

It is expected that the multi-disciplinary team would include obstetricians and gynaecologists, psychiatrists, ultrasonographers, neonatologists, paediatricians, geneticists, nursing staff, social workers and trained counsellors. Such a team should communicate with the mother’s general practitioner to whom the patient will ultimately return. It is important to allow an adequate period of time between counselling and performing a termination of pregnancy. This overrides the usual clinical priority to perform termination earlier rather than later because of the technical difficulties encountered with later terminations of pregnancy. If the parents decide that they wish to terminate the pregnancy, the procedure performed will be dependent on their wishes and on the clinical details of the pregnancy.

 

8.3 The care of the mother post-termination

Careful consideration should be given to the mother’s accommodation after the termination. It may be inappropriate to place her in a post-natal ward where there are newborn babies.

Any medical complications that arise following any procedure must be managed in accordance with best practice.

The psychological care of the mother needs to continue immediately after the termination and extend as long as needed, offering support as required.

The grieving that results from the termination of a wanted baby is not dissimilar to the grieving that results from the death of a child. The grieving is longer and different to that experienced by women who have abortions for psychosocial reasons who typically are relieved and want to forget the experience.

Although ongoing psychological care is not always accepted, it remains important that it is offered. The maintenance of an open door policy, allowing mothers to return for further psychological care when they are ready is to be encouraged.

 

8.4 The disposal of fetal remains and the handling of an infant stillborn

In disposing of fetal remains and handling an infant stillborn, the overriding consideration is to do so with respect and within the wishes of the parents.

Parents should be able to hold, name and mourn their stillborn child. They should also able to arrange for funeral arrangements. If they do not wish to arrange a burial, the hospital would take over the arrangements.

Difficulties for staff may arise when the newborn infant takes a few breaths after being delivered. This may occur before the stage of viability or, in the case of the infant with lethal abnormalities may occur after the stage of theoretical viability. The procedures that would be followed in such instances should have been well thought out with the consensus of the parents and the treating team. Resuscitation of such an infant is inappropriate.

While in most instances the fetal diagnosis is already known, pathological examination may still be desirable. It may be necessary to examine the stillborn to further clarify the diagnosis, to quantify the risk of recurrence to assist future genetic counselling or to collect information to develop a genetic database. However, before a pathological examination is permitted to proceed, the mother’s consent must always be obtained.

The development of a memory folder is considered important when handling the fetal remains or the infant stillborn. Collection of hand or foot prints and photographs may serve as important momentos of the pregnancy.

 

8.5 Risks of late termination vs first trimester abortion or birth at term

It has proven difficult to obtain accurate Australian figures comparing the risks of late termination, first trimester abortion or birth at term. There are multiple variables that influence results including the experience of the proceduralist and the technique used

Nevertheless, it appears to be the consensus opinion that late terminations of pregnancy carry a greater risk than early termination. In experienced hands, dilatation and evacuation carries a lower risk than induction of premature labour.

The morbidity and mortality of late term terminations do not vary significantly from overall maternal morbidity and mortality rates.

 

8.6 Guidance for the Medical Profession

The Board notes these optimal conditions for late term termination and considers that information on best practice should be made available as guidelines for the medical profession.

 

9. Legal aspects of termination. Victorian Law. International Law.

Victorian law does not recognise fetal abnormality per se as an indication for performing a termination of pregnancy. Pursuant to Section 65 of the Crimes Act 1958, for an abortion to be lawful, the medical practitioner must be of the belief that the abortion is "necessary to preserve the woman from a serious danger to her life or her physical or mental health". Consistent with the Menhennitt rule, the risk of the abortion is ‘not out of proportion to the danger to be averted". Although the danger to the mother’s health may be extended to include danger on economic and social grounds, this has not been found to be the practice with late term terminations in Victoria.

Section 10 of the Victorian Crimes Act 1958 that relates to the offence of "child destruction" is also of relevance in any examination of the legal issue relating to late term terminations of pregnancy. Fetal abnormality is not recognised as justification for performing an abortion. In fact, it is an indictable offence to destroy the life of a child capable of being born alive. Although there is no definition in the Act of when a child is "capable of being born alive", it does state that if a woman was pregnant for a period of 28 weeks or more, there is prima facie evidence for this. Issues of fetal viability are of relevance in the interpretation of a child "capable of being born alive".

Under the provisions of the Victorian Registration of Births, Deaths and Marriages Act 1959, if a child dies after the 20^th week of pregnancy or weighs 400 grams or more, it must be registered as a stillborn child. At Monash Medical Centre and the Royal Women’s Hospital, late term terminations of pregnancy are registered and a perinatal death certificate is completed, in accordance with the requirements of the law.

It has been argued recently by Fleming and Hains (ref 59) that the unborn child has important rights under international law. The United Nations Declaration of Rights of a Child states that the child requires special safeguards and care by reason of physical and mental immaturity. The authors claim that this should include appropriate legal protection before as well as after birth.

However, this declaration defines the child as a person under the age of 18 but does not define whether this commences at birth or at an early age. As there is no consensus on when childhood commences, it remains unresolved whether there are legal implications for termination of pregnancy under Australia’s international treaty obligations.

 

10. Training and the continuity of service

The Board’s inquiries confirmed that there is a very small number of well trained medical practitioners who are qualified and are willing to perform late term terminations of pregnancy where this is clinically indicated within the state of Victoria.

The deficits in training and succession planning would therefore appear to be a potential threat to the availability and continuity of high quality, comprehensive services for Victorian women. The Royal Australian College of Obstetricians and Gynaecologists and Directors of Medical Services may be in the best position to address these issues.

The training of other personnel to ensure the continuity of high quality services is also important. The recruitment and training of nursing staff, social workers, psychologists and other counsellors who possess excellent interpersonal skills, empathy and a willingness to work in the area is essential to the provision of support for families who are faced with this very difficult decision.

 

Acknowledgements

The Medical Practitioners Board of Victoria is grateful for the assistance of many individuals, professional bodies and organisations that put a great deal of time and effort into providing thoughtful and helpful submissions.

 

Professional bodies

 

The Australian College of Midwives Inc.

The Australian College of Paediatrics

Australian Medical Association (Victoria Branch)

Family Planning Victoria Inc

Mercy Hospital for Women

Monash Medical Centre

Murdoch Institute

The Nurses Board of Victoria

Psychologists Registration Board of Victoria

The Royal Australian College of General Practitioners

The Royal Australian College of Obstetricians and Gynaecologists

The Royal Australian and New Zealand College of Psychiatrists

Royal Women’s Hospital

The Victorian Perinatal Data Collection Unit of the Consultative Council on Obstetric and Paediatric Mortality and Morbidity

 

Other organisations

Abortion Renewal Ministries

ACT Right to Life Association

The Assemblies of God in Australia

Australian Federation of Right to Life Associations

Caroline Chisholm Centre for Health Ethics

Caroline Chisholm Society

Catholic Archdiocese of Melbourne

Catholic Young Doctors Association of Victoria

Celebration for Life

Christian Democratic Party, Doveton Victoria

Christian Medical and Dental Fellowship (Victoria)

East Gippsland Region, Social Questions Committee, Catholic Women’s League

Family Federation of World Peace and Unification

Finrrage (Australia)

Human Life International Australia Inc.

The Institute of Men’s Studies

National Research Co-ordinator - Focus on the Family (Australia)

Open Doors Counselling and Educational Services

Planned Parenthood of Australia

Pregnancy Help Geelong Inc

Pro-Life Victoria (Inc)

Public Health Association of Australia Incorporated

The Right to Life Victoria Inc

Thomas More Centre

Women Hurt by Abortion Inc.

World Federation of Doctors Who Respect Human Life (Queensland Branch)

World Federation of Doctors Who Respect Human Life (Victoria Division)

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