CONTENTS

Chapter 3. Recommendations and best practice statements across the continuum of abortion care

Clinical services Recommendations 11–14: Pain management for surgical abortion and for prior cervical priming (3.3.6)

3.3.6 Pain management for abortion

There is generally some degree of pain with abortion. The need for pain management increases with gestational age. The degree of the pain varies with the age, parity, prior vaginal delivery, history of dysmenorrhoea and anxiety/fear level of the woman undergoing the abortion (131-134). A shorter procedure time has been associated with less pain (131). Neglecting this important element of care needlessly increases anxiety, discomfort and pain, thereby seriously compromising the quality of care and potentially increasing the difficulty of performing the procedure. Pain management should always be available and it should be administered in advance, in anticipation of the onset of pain, or provided to the woman in case it is needed for later use at home.

WhatWhoWhereHow

CLINICAL SERVICES Recommendations 11–14: Pain management for surgical abortion and for prior cervical priming

11. For pain management for surgical abortion at any gestational age:

  1. Recommend that pain management should be offered routinely (e.g. non-steroidal anti-inflammatory drugs [NSAIDS]) and that it should be provided to those who want it; and
  2. Recommend against the routine use of general anaesthesia.

NEW RECOMMENDATIONS BELOW INDICATE PAIN MANAGEMENT THAT IS ADDITIONAL TO NSAIDS.

12. (NEW) For pain management for surgical abortion at < 14 weeks:

  1. Recommend the use of a paracervical block; and
  2. Suggest that the option of combination pain management using conscious sedation[1] plus paracervical block should be offered, where conscious sedation is available.

13. (NEW) For pain management for cervical priming with osmotic dilators prior to surgical abortion at ≥ 14 weeks: Suggest the use of a paracervical block. (See also section 3.3.7 on cervical priming prior to surgical abortion.)

Remark:

  • For cervical priming (Recommendation 13), additional pain medication can be considered, such as the use of intravaginal gel.

14. (NEW) For pain management for surgical abortion at ≥ 14 weeks:

  1. Recommend the use of a paracervical block; and
  2. Suggest that the option of combination pain management using conscious sedation plus paracervical block should be offered, where conscious sedation is available.

Source: Recommendation 11 updated from WHO (2012)(19). Recommendations 12–14 are new.

Note on updating of the recommendation: Recommendation 11a was previously published as part of Recommendation 14 in WHO (2012) (19), and evidence for it was reviewed using GRADE methodology. After review, in this updated version, we have split the first part of the original recommendation wording to apply to surgical abortion here (11a) and medical abortion in a separate recommendation (15) and revised the wording to mention provision, and we have separated and revised the wording of the second part of the recommendation referring to general anaesthesia (Recommendation 11b).

For information regarding which health workers can provide this intervention, refer to Recommendations 24 and 26 for surgical abortion (vacuum aspiration and D&E).

For information regarding which health workers can provide For information regarding which health workers can provide this intervention, refer to Recommendations 24 and 26 for surgical abortion (vacuum aspiration and D&E).

Implementation considerations
  • Sufficient supplies and stocks of pain medications should be ensured.
  • Training of providers in abortion care should include pain management, in particular the technique for administration of paracervical block.
Rationale for Recommendations 11b and 12

An update of an existing Cochrane Review[2] served as the evidence base for assessing the pain management regimens for surgical abortions at < 14 weeks of gestation. Thirty studies reporting on pain management for surgical abortion were identified by the search strategy. Of these studies, nine studies – conducted in France, the Islamic Republic of Iran, Norway, Turkey and the USA – are the focus of of the evidence base for these recommendations. Six studies compared the paracervical block (PCB) with a placebo. One study compared the PCB with general anaesthesia. Two studies compared conscious sedation[3] plus PCB versus PCB alone. A summary of the evidence is presented in Supplementary material 2, EtD framework for Pain management for surgical abortion < 14 weeks.

Combination pain management using conscious sedation plus PCB: Mean pain scores were lower in the group of women who received conscious sedation and PCB compared with the women who received a PCB alone, based on moderate-certainty evidence. In addition, satisfaction with their pain management was higher among the former group of women, based on high-certainty evidence.

Paracervical block (PCB): Both with and without conscious sedation, mean pain scores were lower in the group of women who received a PCB compared with the women who received a placebo, based on moderate-certainty evidence. Fewer women required additional analgesic medication, based on high-certainty evidence, and in the former group of women was high, based on moderate-certainty evidence.

General anaesthesia: Pain scores were lower in the group of women who received general anaesthesia compared with PCB alone, based on moderate-certainty evidence. However, discussions on the resources required, cost effectiveness, feasibility and equity related to administering general anaesthesia resulted in a conclusion that did not favour the intervention. In addition, Recommendation 11b aligns with the existing statement that vacuum aspiration does not require an operating theatre (19).

Rationale for Recommendations 13 and 14

A systematic review assessed the pain management regimens for surgical abortions at gestational ages ≥ 14 weeks. Three studies reporting on pain management for D&E were identified by the search strategy, all of which focused on pain management during the cervical priming prior to the surgical procedure. A summary of the evidence is presented in Supplementary material 2, EtD framework for Pain management for surgical abortion ≥ 14 weeks.

Mean pain scores were lower in the group of women who received a PCB compared with the women who received a placebo, based on high-certainty evidence. Satisfaction in the former group of women was high, based on moderate-certainty evidence. An intravaginal gel can be used as an alternative method of pain control; more women had a lower pain score after receiving the gel compared with those who had a PCB, based on low-certainty evidence. Cervical priming was performed with laminaria. Discussions on the values and preferences of women regarding pain management during surgical abortion, and on the resources required and the feasibility of PCB administration resulted in a determination that favoured the intervention.

No studies were identified that focused on pain management for the D&E procedure. Therefore, the expert panel came to a consensus to align the recommendations to those for pain management for surgical abortion at < 14 weeks of gestation (see Recommendation 12).

Related topics / recommendations

Footnotes

  1. Conscious sedation is also known as intravenous (IV) sedation or moderate sedation. See definition in Glossary. ↩
  2. A Cochrane Review is a systematic review of research in health care and health policy that is published in the Cochrane Database of Systematic Reviews. ↩
  3. Conscious sedation is also known as intravenous (IV) sedation or moderate sedation. See definition in Glossary. ↩

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