Patients for whom a second trimester termination is planned should have a plan of care and a discussion of the methods. Medical-Surgical consents and Massachusetts Department of Public Health consents appropriate for the procedure should be obtained and documented. If appropriate, consent for disposition of fetal remains should be obtained.

Eligibility for second trimester termination should be determined by the best estimate of gestational age. The calculation of gestational age should be consistently applied and transparently obtained by all available dating criteria. Ultrasound verification of gestational age and determination of biparietal diameter is preferred, ideally within one week of the procedure. Gestational age limits should be in accordance with state law.

Prior to Second Trimester Pregnancy Termination

• obtain medical and obstetrical history;
• confirm the gestational age;
• conduct a physical exam; and
• counsel the patient regarding potential risks, agents and methods for the chosen procedure, and the possible risks of the chosen procedure.

The plan of care should take into consideration:

• the patient wishes for an intact fetus;
• the patient wishes not to have a labor and delivery;
• availability of care providers experienced in second trimester pregnancy termination procedures;
• medical or obstetrical co-morbidities;

Plan of care may include, but not be limited to:

• discussion of the appropriate location for the proposed procedure;
• anesthesia consultation as indicated; and
• consultation with Social Work, Chaplaincy, or both as desired.

Institutional Guidelines 

Each facility shall develop guidelines for  second trimester pregnancy termination to include, at a minimum, details regarding:

• procedures,
• medications,
• monitoring the patient,
• description of training and competency of personnel,
• availability of a physician who can manage complications,
• use of cervical ripening agents,
• potential role of intra-operative ultrasound,
• potential role of feticidal agents, and
• strategy/plan in the event of a live birth.

Methods of Second Trimester Pregnancy Termination

Methods of second trimester termination include dilation and evacuation, and induction of labor. Hysterectomy and hysterotomy are not considered primary methods for terminating a second trimester pregnancy.

Documentation

Documentation should include, but not be limited to:

• discussion of procedures or methods, and their risks and benefits;
• consents for medical-surgical procedures, and the Massachusetts Department of Public Health consents and disposition of fetal remains form, if applicable;
• administration of medications: time, date, dose;
• administration of medications or the use of hygroscopic dilators (e.g., laminaria, dilapan), including date, time, and number placed, as needed for cervical preparation;
• patient’s clinical response;
• delivery or removal of fetal tissue and completeness; and
• complications and need for additional procedures.^1,2

1. Second-trimester abortion. ACOG Practice Bulletin No. 135. June 2013. Reaffirmed 2015. American College of Obstetricians and Gynecologists.
2. Abortion Policy. College Statement of Policy. As issued by the College Executive Board. American College of Obstetricians and Gynecologists. November 2014.