Surgical terminations after 12 weeks are unlikely to be widely available in Ireland this year, according to new guidelines on the treatment of babies with fatal foetal anomalies.
“It is unlikely that surgical termination of pregnancy after 12 weeks will be widely available nor that D&E (dilatation and evacuation) after 14 weeks will be offered in Ireland in 2019, but this might change over time,” the guidelines from the Institute of Obstetricians and Gynaecologists state.
The Institute sought, and received, an assurance from the Department of Health chief medical officer Dr Tony Holohan that doctors carrying out procedures under new abortion legislation would not be prosecuted.
“A medical practitioner carrying out a medical procedure, which includes the prescribing of a drug or medicine, intended to end the life of a foetus within the provisions of the legislation will not be subject to prosecution,” Dr Holohan states, in a letter to the Institute included as an appendix in the document.
For some, termination of pregnancy in Ireland “may still not be an option”, the guidelines state.
“This may be for complex reasons including legislative restrictions in Ireland for non-fatal but major foetal anomalies, the need to travel to another country for treatment, financial or social considerations, as well as to access specific medical procedures.”
“During this time, and before termination of pregnancy, these parents should be assisted with preparing for the birth and death of their baby. Opportunities for memory-making can be discussed and planned, as well as the logistics around making arrangements for the baby when the parents are back in Ireland.”
Ultrasound
All women must have equal status to ultrasound services to date pregnancies, the guidelines state. Prompt referral to a foetal medicine specialist should follow within 24 to 72 hours where a major foetal anomaly is suspected, and a foetal medicine specialist should be involved where a termination is being considered.
The options of continuing the pregnancy with perinatal palliative care for the baby, or terminating the pregnancy should be discussed with the parents, the document says.
“Women should have access to accurate and objective information and, if required, counselling and support. There should be local arrangements in place for providing value-neutral information to women about termination of pregnancy.”
If either the parents or the medics are still uncertain about the diagnosis or prognosis, a second opinion, either internal or external, should be sought.
The guidelines also recommend bereavement support “all along the care pathway and . . . through the baby’s death and beyond”, regardless of which option parents choose.
“For some, terminating a pregnancy is the correct decision for them and their family, but it is really what we understand as a ‘choice’. It is often traumatic. Others may benefit from an alternative approach and continue their pregnancy.
“A perinatal palliative care approach can provide support to families who make either of these decisions, and hospital guidelines must be structured in a way to allow this.”
The documents contains a non-exhaustive list of fatal foetal anomalies.
Feticide can be performed before a termination procedure after 21 weeks and six days of gestation to ensure there is no risk of a live birth, the guidelines state. This should only be performed at a major referral centre with appropriately trained staff.
Conscientious objections
Doctors who conscientiously object to abortion “are obliged to make the necessary arrangements for the transfer of care of the pregnant woman” so she can have a termination.
About 2-3 per cent of pregnancies are complicated by congenital abnormalities, of which about 15 per cent are life-limiting or potentially so. Major congenital anomaly was the main cause of death in one-quarter of the 250 stillbirths in Ireland in 2016.
Section 11 of the Health (Regulation of Termination of Pregnancy) Act 2018 allows for terminations to be carried out where two medical practitioners, one of them an obstetrician, finds the condition of the foetus is likely to lead to its death either before, or within 28 days of, birth. Women can seek a review of a refusal by doctors to perform a termination.
According to the guidelines, terminations can be performed surgically before 14 weeks using a technique of vacuum aspiration after administration of the abortion pill. After this gestational age, dilatation and evacuation (D&E) becomes necessary, but this should only be performed by specialists with access to the necessary instruments and who have a sufficiently large caseload to maintain their skill levels.
