1st point: If you have the opportunity before the pregnancy test results are available, talk with her about why she thinks she is pregnant, and whether it is even appropriate to be doing a pregnancy test at this time. Many women will have performed a home pregnancy test and are looking for confirmation of the result (or hoping the result is wrong). Research indicates that most women make a decision about their pregnancy within one day of receiving pregnancy test results, which probably means that most women in this setting already suspect they are pregnant and have some sense of how they feel about the pregnancy prior to taking a test (Finer, 2006).

2nd point: It is also helpful to know if the woman has thought through her reaction to the potential test results. Most women make a decision about their pregnancy within one day of receiving pregnancy test results, which means most women suspect they are pregnant and have some sense of how they feel about the pregnancy (Finer, 2006)

Reference: Finer, L. B., Frohwirth, L., F., Dauphinee, L. A., Singh, S. & Moore, A. M. (2006) Timing of steps and reasons for delays in obtaining abortions in the United States. Contraception, 74, 334-344.

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1st point: When delivering the test results, it is important to deliver pregnancy test results in a neutral and clear way. For example rather than saying “Congratulations, your test is positive”, it is better to say: “Your test result is positive, which means that you are pregnant.” Don’t make assumptions about what the woman wants the result to be.

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1st point: Remaining silent after giving the result allow the woman to have time to respond. As HCPs, we often want to “fix things” by giving information, providing referrals, etc. These are all useful interventions, but wait to allow the woman to respond and share her feelings before proceeding.

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1st point: For the woman who does not want to be pregnant, a negative result provides a “teachable” moment. Following a negative test she may be highly motivated to use a reliable method of birth control and to learn about safer sex practices and emergency contraception.

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1st point: In the U.S., progestin-only EC is available on the drug store shelf without age restrictions to women and men. Look for Plan B One-Step, Take Action, Next Choice One-Dose, My Way or other generics in the family planning aisle. Ulipristal acetate (Ella), a progesterone agonist/antagonist, is a one-time 30 mg dose that is effective up to 5 days after unprotected intercourse and requires a prescription. When taken within 72 h of unprotected sex, the progestin only (levonorgesterol) EC prevents approximately 50% of pregnancies while ulipristal prevents up to two-thirds of pregnancies. 2nd point: The Paraguard (copper) IUD can be used for emergency contraception. For women who want an IUD for contraception, the ParaGuard can be placed within 5-7 days after unprotected intercourse as a way to both prevent pregnancy and establish a long-term contraceptive method. Currently there is no data to recommend the use of the levonorgestrol (LNG) IUD as emergency contraception.

3rd point: Emergency contraception is considered safe while breastfeeding (U.S. Medical Eligibility Criteria for Contraceptive Use, 2010). The World Health Organization reports no medical contraindications to emergency contraception (http://www.who.int/mediacentre/factsheets/fs244/en/ July 2012).

4th point: Overweight or obese women may experience higher failure rates with ECs. The risk of pregnancy was four-times greater in obese women with levonorgesterol ECs compared with normal-weight women. Obese women who used ulipristal were twice as likely to experience EC failure compared with nonobese women.

References: 1.Emergency insertion of a copper IUD is more effective than use of EC pills, reducing the risk of pregnancy by more than 99% (Belden, P., Harper, C. C., & Speidel, J. J. (2012). 2.The copper IUD for emergency contraception, a neglected option. Contraception, 85(4),

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338-339. doi:10.1016/j.contraception.2011.08.0163. http://www.who.int/mediacentre/factsheets/fs244/en/ July 20124.U.S. Medical Eligibility Criteria for Contraceptive Use, 2010). 5.The World Health Organization http://www.who.int/mediacentre/factsheets/fs244/en/ July 2012.6.Glasier A. Emergency contraception: clinical outcomes. Contraception87(3), 309–313 (2013). 7.Glasier AF, Cameron ST, Blithe D et al. Can we identify women at risk of pregnancy despite using emergency contraception? Data from randomized trials of ulipristal acetate and levonorgestrel. Contraception84, 363–367 (2011).8.Moreau C, Trussell J. Results from pooled Phase III studies of ulipristal acetate for emergency contraception. Contraception86, 673–680 (2012).

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1st point: Use language that is sensitive and nonjudgmental.

2nd point: For a more detailed discussion of options counseling, see the ppt. Options Counseling for Unintended Pregnancy at www.abortionaccess.org

3rd point: It is important to know community resources for prenatal care, adoption services and abortion care. It is useful to have brochures or business cards with contact information from such organizations available to provide to women.

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1st point: The decision to continue or terminate a pregnancy is motivated by any number of interrelated social factors. A study by Biggs et al. (2013) identified reasons for seeking abortion including financial reasons (40%), timing (36%), partner related reasons (31%), and the need to focus on other children (29%). Most women reported multiple reasons for seeking an abortion crossing over several themes (64%).

Reference:Biggs, M. A., Gould, H., & Foster, D. G. (2013). Understanding why women seek abortions in the US. BMC Women's Health, 13(1), 1-13. doi:10.1186/1472-6874-13-29

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1st point: If a partner or support person is in the waiting room, does the woman want the person involved in the discussion?

2nd point: The Guttmacher Institute, which advances sexual and reproductive health worldwide through an interrelated program of social science research, public education and policy analysis, provides a state by state “State Facts about Abortion” which provides current information about parental notification or consent requirements. http://www.guttmacher.org/statecenter/sfaa.html

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1st point: Provide has developed a training tool titled, Referrals for Unintended Pregnancy: A Curriculum for Health and Social Service Providers.

Health care and social service providers—nurses, physicians, counselors, social workers, case managers, and ministers—often serve as a critical link to getting women quality, compassionate care for a range of health care needs, including reproductive health care. Provide’s experience working in health and social service systems has shown us that these same individuals are both willing and able to play an essential role around pregnancy options counseling and access to prenatal care, abortion, or adoption resources. These professionals often do not have the tools or support to assist women facing unintended pregnancy. This is particularly true of situations where a woman does not want to continue her pregnancy.

Given this gap, Provide trains health and social service providers to offer non-judgmental, all options counseling and referrals to their clients and patients. Visit http://provideaccess.org/referralscurriculum/

2nd point: Adoption Information is presented here as many health care professionals as less knowledgeable about types of adoption: open, closed, familial adoption, state adoption or foster care. Most adoption professionals today, whether agencies or private attorneys, are moving toward some degree of openness in their practice. It has been widely recognized that the completely closed adoptions that were the norm in years past have not lead to entirely healthy emotional outcomes either for adoptees or birthmothers. Openness in

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adoption can range from simply sharing information prior to placement between the birthmother and adoptive family, to arrangements in which birthmothers choose the adoptive family and maintain ongoing contact once the child is born. It is important that birthmothers work with agencies that support them in creating adoption plans and agreements that are noncoercive and fully explain her rights and the range of options available to her. Many women who say that they would never consider adoption are more open to the option when they are educated about their role in choosing a family and adoption arrangements in which they would have ongoing contact with the child.

Some women will speak to familial adoptions, in which a member of their family assumes legal rights of the child. While this may seem like an easier solution, referring these women to agencies who can help them navigate the legal and emotional nuances of this process is important.

Finally, many women associate “adoption” with foster care. Educating patients about their active role in choosing a family for their child and empowering them in acknowledging adoption as a responsible and loving parenting choice can help them differentiate adoption plans from situations in which the state intervenes to terminate their parenting rights. For more information on this, contact Open Adoption & Family Services www.openadopt.org.

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1st point: Be sure to ask the woman if she has any concerns.

Resources:

Guidelines for management of nausea and vomiting of pregnancy at ARHQ. National Guideline Clearinghouse: http://www.guideline.gov/summary/summary.aspx?doc_id=10939

March of Dimes: Pregnancy and Newborn Health Center for Keeping Healthy and Things to Avoid handouts: http://www.marchofdimes.com/pnhec/159.asp

Resources and referrals for genetic counselors at March of Dimes: http://www.marchofdimes.com/pnhec/4439_15008.asp

A White Paper on Supporting Healthy Pregnancies, Parenting, and Young Latinas’ Sexual Health: http://www.latinainstitute.org/documents/NLIRH-HealthyPregnancyWhitePaper9.11.09FINAL.pdf

National Advocates for Pregnant Women works to secure the human and civil rights, health and welfare of all women, focusing particularly on pregnant and parenting women, and

those who are most vulnerable - low income women, women of color, and drug-using women: http://www.advocatesforpregnantwomen.org/

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1st point: Be sure to ask the woman about her concerns.

2nd point: If she complains of abdominal pain, spotting or bleeding along with a positive pregnancy test, she needs a workup for an ectopic pregnancy.

3rd point: Is she at risk for intimate partner violence? It is estimated that one in five women will be abused during pregnancy.

http://www.cdc.gov/reproductivehealth/violence/IntimatePartnerViolence/index.htm

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1st point: The ANA Code of Ethics provides an ethical framework for nursing care and directs the nurse “to practice with compassion and respect for the inherent dignity, worth and uniqueness of every individual, unrestricted by considerations of social or economic status, personal attributes, or the nature of health problems”. In 1989, the ANA addressed the need for nurses to examine their conflicts arising from professional and personal values and resolve these in a way that ensures patient safety and preserves the professional integrity of the nurse (see “The Right to Accept or Reject an Assignment” statement for a discussion of potential conflicts related to moral, ethical, or religious views).

2nd point: Association of Women's Health, Obstetric and Neonatal Nurses states that nurses have the right, under responsible procedures, to refuse to assist in […] abortion or sterilization procedures, in keeping with their personal moral, ethical, or religious beliefs. Nurses have the professional responsibility to provide high quality, impartial nursing care to all patients in emergency situation, regardless of the nurses' personal beliefs […] and to provide nonjudgmental nursing care to all patients, either directly or through appropriate and timely referral.

3rd point: Professional nursing organizations, such as the American College of Midwives (ACNM), National Organization of Nurse Practitioner Faculties (NONPF), National Association of Nurse Practitioners in Women’s Health (NPWH) have codified the ANA Code of Ethics by providing ethical and legal guidelines for their members.

References:

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1. American Nurses Association, 2001. Code of ethics for nurse with interpretive statements. http://nursingworld.org/ethics/code/protected_nwcoe813.htm

2.Beal & Cappiello, 2008. Professional Right of Conscience. Journal of Midwifery & Women’s Health. 53 (5), 406-412.3.Cappiello, J., Beal, M., and Hudson-Gallogly, K (2011). Applying ethical practice competencies in the prevention and management of unintended pregnancy. Journal of Obstetric, Gynecologic and Neonatal Nursing, Nov/Dec., 40 (6), pp. 808-16.

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1st point: There are several types of pregnancy tests. Immunometric tests, also known as ELISA or monoclonal antibody tests, have become the most common type of test, both at home and in clinical settings, because they are easy to use, non-invasive, highly sensitive and inexpensive.

2nd point: Results can be accurate as early as the time of the missed period. Some tests are accurate within 7-10 days of conception. It is rare to have false negatives, and even rarer to have false positive tests. However, it is important to understand that if a test is negative, it may not be a false negative but may simply be too early to be positive. If this is a concern, repeat the test in a few days or a week.

3rd point: The accuracy of test results is enhanced in very early pregnancy with an first morning urine collection as a more concentrated specimen will have higher levels of hCG.

4th point: Home pregnancy tests may have a decreased accuracy rates related to specimen collection techniques (residue in collecting container), errors in timing or errors in interpretation of the test.

5th point: An older type of test--agglutination tests--are no longer common because monoclonal antibody tests provide positive results much earlier and at comparable cost, although the agglutination tests remain available for specific indications. References:

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1st point: Currently available assays are more than 99% accurate in diagnosing pregnancy.

2nd point: Beta HCG hormone can be measured quite accurately as a qualitative test (positive or negative) or as a quantitative test with a specific value of milli-international units per milliliters. Serial quantitative tests are repeated every 2 to 3 days in special conditions of pregnancy: to assess the viability of a pregnancy, to determine if a miscarriage is occurring or to diagnosis an ectopic pregnancy.

3rd point: Beta HCG testing is more expensive than urine testing and must be ordered through a laboratory. It is not available in an office-based technology.

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1st point: Serum hCG becomes detectable within 24 hours after implantation (although not detectable this early with commonly used technology) and increases progressively.

2nd point: A normal pregnancy will have an approximate doubling of levels in a 48 hour period. A lower rate of increase may indicate an ectopic pregnancy or an intrauterine pregnancy destined to miscarry. Higher than expected levels are found with multiple pregnancies. Levels should not be used for dating of pregnancy as levels are too variable.

Reference: Tietz, NW (ed): Clinical Guide to Laboratory Tests, 4thd edition, Phil. W. B. Saunders, 2006.

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