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Specific Interest Zoom Chair : Hello and good evening to tonight's webinar This is our second REC GP and all caps webinar series.
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Specific Interest Zoom Chair : GPS and medical abortion challenges barriers and safety across Australia, my name is Claire Pearson and i'm the education and events officer in the specific interest faculty and i'll be your host for this evening.
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Specific Interest Zoom Chair : So tonight, I just wanted to start off with a bit of housekeeping so we'll be recording tonight's webinar and you receive a copy and the coming week.
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Specific Interest Zoom Chair : And also where's my control panel, and if you can't see what you see on the screen here, you call control panel will appear as a bar at the bottom of the presentation screen if you hover your mouse over it.
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Specific Interest Zoom Chair : And tonight we're in listen only mode so you'll need to use the zoom control panel to.
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Specific Interest Zoom Chair : interact with us tonight we have put all attendees on mute to ensure learning will not be disrupted by background noise but you'll still get the chance to interact with your peers, using the Q amp a and the chat box at the bottom of the screen.
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Specific Interest Zoom Chair : Please do not enter any personal information outside of your name and your question as other attendees will be able to see this.
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Specific Interest Zoom Chair : Someone else's asked a question that you would like answered you can give it a thumbs up and the questions that have more wax will move to the top of the list and can be asked our dedicated Q amp a session at the end of the webinar.
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Specific Interest Zoom Chair : So tonight's webinar is worth two cpd points and for our CG women's your cpd points will be uploaded on the cpd dashboard within the next 30 days, and now I will pass on the presentation to GP hosts Dr amy motion to begin with an acknowledgement of country.
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Dr Amy Moten: Okay, and so to start tonight's webinar, I would like to acknowledge the traditional custodians of the various land from which each of us are joining in this webinar from today, I personally am on the land to get out of people, I wish to pay my respects to elder's past, present and merging.
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Dr Amy Moten: So the rsvp is a proud partner with the all caps network which is central the Australian contraception and abortion primary care practitioner support network.
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Dr Amy Moten: And the asked caps network isn't an html oC funded online community of practice developed in partnership with the rsvp rounds called abner the PSA.
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Dr Amy Moten: and others key stakeholders, the primary health care providers are interested in increasing access to long acting reversible contraception and medical abortion.
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Dr Amy Moten: GPS practice nurses and pharmacists are invited to join in, there is no cost to do so.
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Dr Amy Moten: This community of practice is designed to help you as a clinician connect with your peers and access expert knowledge and information, besides moderated by expert clinicians and the all caps team.
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Dr Amy Moten: The network will connect you with other GPS pharmacists nurses around Australia, who also provide like and medical abortion services.
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Dr Amy Moten: That provide access to training, education opportunities relating to like insertion and medication abortion provision.
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Dr Amy Moten: they'll also enable us with questions to an expert network give you access to resources guidelines referral forms and patient handouts.
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Dr Amy Moten: Keep me connected with the latest news and research related Larkin medical abortion.
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Dr Amy Moten: And the ascap team also ask that you continue to research and to provide the identified and aggregated PBS MPs data, as this will help evaluate the impact of decide.
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Dr Amy Moten: to sign in the online community of practice, please find the link on the screen below and in your chat box now we'll also send it directly to your email after the webinar and if you have further questions you can also email us kept strictly on the email on your screen.
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Dr Amy Moten: So, as mentioned my name is Dr amy motion i'm a GP medical educator for family planning or shiny thing and also Chair of the area's EDP sexual health medicine network in a specific interest group and we're very pleased to be joined tonight with Dr Miranda surely who's our speaker.
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Dr Amy Moten: Dr sherry began her career as far as working in microbial genetics before returning to the venue in 2004 to study medicine.
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Dr Amy Moten: After completing her medical degree, Dr shelley made are nearly choice to take up a create in sexual health medicine, she completed training with the Royal australasian college of.
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Dr Amy Moten: physicians and the royals tranquilizer general practice Dr shirley and lived in the camp or raising since 2002 and has provided JP services to her local community since 2013.
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Dr Amy Moten: After being based in campus sexual health Center for seven years in 2018 Dr shirley started a private practice in section with medicine and is the only private central division in her region.
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Dr Amy Moten: So we decided to move on to a poll now and ask everyone, what is your role in primary care, so the answers will be GP practice nurse Sexual Health Commission medical student GP in training or other and we'll give you a few moments to that.
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Dr Amy Moten: Okay, so it looks like we've got quite a few GPS on tonight so 67% or GPS with another 23% GPS in training.
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Dr Amy Moten: But we're also seeing a blend of other professions which is fantastic because the all caps network want to reach as many people as possible, thank you all for answering that question or now pass on the presentation to Dr Miranda sheerly to speak on GPS and medical abortion.
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Dr Miranda Sherley: thanks for that introduction amy and welcome everyone it's wonderful see so many people here giving up their evening to be present.
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Dr Miranda Sherley: And, as you know, the focus of today's presentation is going through medical abortion in the gap setting.
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Dr Miranda Sherley: players, going to be kind enough to be working through the slides for me so you'll hear me giving instructions Thank you so much.
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Dr Miranda Sherley: we're going to be covering an overview of what medical abortion is reviewing the legal regulation of abortion in Australia.
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Dr Miranda Sherley: Looking at some of the barriers and challenges to providing an accessing abortion services in a gap setting and hopefully some strategies to work around those barriers and challenges next slide please.
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Dr Miranda Sherley: everything starts, of course, with an unwanted pregnancy, without contraception it's estimated that there's an 80% chance that someone in a regular sexual relationship will fall pregnant within a year.
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Dr Miranda Sherley: But even with contraception there's still a chance of pregnancy, especially if doses of mist or their medications out of date or it's not used correctly.
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Dr Miranda Sherley: And in Australia it's estimated that a quarter all pregnancies around plan and all those around about a third go on to an abortion next slide.
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Dr Miranda Sherley: it's really important to talk to people when they come in to see you with a new pregnancy, because they may not know what all of their options are, and it is part of that from your consent process.
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Dr Miranda Sherley: Importantly, I think people don't necessarily realize that adoption is an option or that there's both surgical and medical abortion options out there.
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Dr Miranda Sherley: Next slide where about focusing on those two options surgical and medical terminations but I thought this might be a good opportunity to see what everyone's little experience of medical abortions is as we're heading into this talk tonight so back to you Claire for a quick poll.
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Dr Miranda Sherley: All right, thank you, if everyone could put in the answer, and let us know how much you do know about medical abortion or how much experience you've got with it, that would be wonderful.
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Dr Miranda Sherley: So there's a fair bit of a spread that I can see, and I think that's wonderful because, hopefully, those of you who haven't had much experience with medical abortions, will be able to.
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Dr Miranda Sherley: Give us some ideas about what barriers they have been or still are that are stopping you being more actively involved in.
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Dr Miranda Sherley: Those who are up the other end who provided some abortions or provide that service more regularly might be able to give us some hints about the way you've overcome the barriers that the other people are bringing up, we could move on to the next slide please.
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Dr Miranda Sherley: let's start with a general comparison of surgical versus medical abortions.
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Dr Miranda Sherley: The biggest differences, to my mind, in terms of timing and location surgical termination really has to take place in a hospital or dedicated clinic.
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Dr Miranda Sherley: And it carries anesthetic and surgical risks but it's over and done with quickly, whereas medical abortion can be carried out in the privacy person's own home but it involves bleeding and cramping pain.
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Dr Miranda Sherley: And it needs follow up the relative costs are very variable and we will come back to cost a little bit later on next slide please.
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Dr Miranda Sherley: What about success rates and complications between those two different options well there is a slightly higher risk of continued pregnancy or retain products with medical abortions, but overall there's numbers are still very low next slide.
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Dr Miranda Sherley: what's involved in a medical abortion, the pregnancy needs to be confirmed as being within 63 days so that's nine weeks of gestation and being introduced RON.
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Dr Miranda Sherley: qualified person and that might be someone who has iran's called qualification, or it might be someone who's done the Ms to step training Program.
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Dr Miranda Sherley: preschool prescribes the medication Ms to step and that is dispensed by registered pharmacy who also have to complete the training program and be registered with the Ms to step Program.
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Dr Miranda Sherley: The medications are dispensed and patient who takes them over a two day period.
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Dr Miranda Sherley: Next slide.
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Dr Miranda Sherley: The first step is me for this time which blocks progesterone holding the pregnancy and it sensitize as the uterus across the glands.
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Dr Miranda Sherley: A small number of pregnancies miscarry at this point, but it is still recommended to continue to step two, even if it is bleeding to be absolutely sure.
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Dr Miranda Sherley: Importantly method pristine has anti political quarter quarter effects, and it can block the action of steroids, such as decks and methods on are pregnant alone for people who are dependent on those next slide.
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Dr Miranda Sherley: second step is misoprostol, this is a synthetic prostate gland and it softens the cervix further and it induces uterine contractions so that the products are conception are expelled.
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Dr Miranda Sherley: Importantly, it is not solid it's placed between the teeth and the cheek to be absorbed across the vehicle membrane, so this is a key point at which the process can go wrong if it's not explained clearly.
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Dr Miranda Sherley: After 30 minutes what's going to be absorbed will be absorbed and so it's okay at that point to rinse and swallow next slide please.
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Dr Miranda Sherley: When can't you use Ms to step well it won't work for an ectopic pregnancy and it's not approved, to be used, after 63 days which essentially reflects waning efficacy later in pregnancy.
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Dr Miranda Sherley: It can't be used if there's an iud still inside you and the risk of severe bleeding precludes those who have a bleeding disorder or on anticoagulants.
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Dr Miranda Sherley: or people who are more than two hours away from an available transfusion service, the steroid blocking effects, make it unsafe for someone who's dependent on glencoe quarter quote so that might be, for example, someone with addison's.
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Dr Miranda Sherley: or someone with severe asthma that needs a steroids on a regular basis.
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Dr Miranda Sherley: As with absolutely any medication we wouldn't use it in a person with a severe allergy to any of the components, of course, and finally there is thought to be rescued triggering episodes of porphyria in people who are susceptible to that condition.
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Dr Miranda Sherley: Next slide.
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Dr Miranda Sherley: Caution is needed in anyone who would be at risk from the heavy blood loss, which is where the severe anemia and ischemic heart disease, and presumably congested cardiac failure come in.
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Dr Miranda Sherley: or by people who might need corticosteroid so again someone with very brittle esmer and a history of hospitalization for their asthma or someone who might be affected by vomiting low food intake or the physical stress of a miscarriage.
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Dr Miranda Sherley: Next slide.
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Dr Miranda Sherley: Now, as I see it in a perfect world, the process would take place over three visits.
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Dr Miranda Sherley: At the first visit thorough history, establishing a timeframe to the pregnancy assessing for risks and content indications should be done.
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Dr Miranda Sherley: Pregnancy options should be talked through and ongoing contraceptive needs should be talked about as well, and the patient sent away with forms blood tests and an ultrasound.
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Dr Miranda Sherley: Also, a very good opportunity to offer STI screening because being pregnant, we know they're sexually active so it's time to think about those other things to.
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Dr Miranda Sherley: Next slide.
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Dr Miranda Sherley: second visit is the time to check those dates, to make sure the pregnancy does look like it's the dates that are expected and, within that 63 day mark.
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Dr Miranda Sherley: it's, the most important thing in this visit, I think he has to really clearly explain to the patient exactly what to expect.
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Dr Miranda Sherley: What they need to do what they should expect to happen in a normal situation, what isn't normal and I think it's ideal to have written instructions and guidance on when seek help.
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Dr Miranda Sherley: And what numbers to call where to go if you do need help, that they can take away at that time, they should also have a support person who can be with them through that medical abortion.
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Dr Miranda Sherley: Some services supplier letter for the hospital in case of emergency.
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Dr Miranda Sherley: And for the Ms to stay medication itself, you need to get an authority approval, so at this visit you would either phone or use the proto system to arrange for that authority script.
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Dr Miranda Sherley: it's also very appropriate to think about providing a script for an anti emetic and for strong pain relief at this time as well.
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Dr Miranda Sherley: beta hcg will need to be checked, on the day that the Miss Christine has taken as a baseline to pay it back to and is usually checks one to two weeks afterwards, and so the patient needs to go away with two forms one for the baseline and one for the follow up.
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Dr Miranda Sherley: Next slide please.
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Dr Miranda Sherley: If possible, a phone call at three days it gives an opportunity to check that things are going according to plan.
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Dr Miranda Sherley: And a third visit at two three weeks is really important it's that opportunity to make sure that the story sounds like the.
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Dr Miranda Sherley: Abortion has gone as to plan to make sure that bleeding has settled down to check the beta hcg and make sure that has been an appropriate dropping levels.
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Dr Miranda Sherley: And again to check in on ongoing contraception, because you can get pregnant within two weeks of a termination, so this is really important next slide.
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Dr Miranda Sherley: There might be some like leading after the me for Chris stone, but things mostly start a few hours after the misoprostol.
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Dr Miranda Sherley: I tell people, it will be worse than bad period with heavy bleeding and cramps the worst of it should be over in a day and it's followed by reading more like a normal period.
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Dr Miranda Sherley: But after that bleeding is finished, to say around about five or six days lighter spotting and bleeding can last for a few weeks next slide.
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Dr Miranda Sherley: Now that we've covered the process itself i'd like to move on to have a look at some of the barriers to access, starting with the law.
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Dr Miranda Sherley: Importantly, the legal situation very substantially around Australia and obviously i'm a doctor, not a solicitor so I relied on a few online resources and, if you will check the actual wording of the laws in your own state, I do suggest the costly site it's really helpful.
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Dr Miranda Sherley: But before we get on to that let's have a look at where everyone is from here tonight.
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Dr Miranda Sherley: lots of people from the east coast, I see, but a smattering from elsewhere if there is anyone who thinks i've got anything wrong for their state, please do drop us a message in the chat box all the Q amp a box.
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Dr Miranda Sherley: let's have a look at the simple version before we get into the nitty gritty so this map shows the age at which termination is allowed in each of the States and territories of Australia and because that looks fairly straightforward, but there is a lot more to it than this next slide.
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Dr Miranda Sherley: New South Wales is my state and here, abortion is legal to 22 weeks and later if another doctor agrees and it's performed in a hospital.
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Dr Miranda Sherley: Importantly, everyone involved must be qualified or they can face in prison, and that includes not just medical professionals, the doctor who is prescribing but.
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Dr Miranda Sherley: The person who procures and supplies the medication as well, which is why it's so important that pharmacies are registered as well.
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Dr Miranda Sherley: counseling has to be offered and conscientious objectors to abortion must provide an alternative service places providing abortions can be protected by 150 meter protests safe zone.
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Dr Miranda Sherley: Next slide.
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Dr Miranda Sherley: Interestingly, and unusually new South Wales also has a form that you have to fill in for the health department and that's meant to be filming online, but you can also print out and filling a hard copy as well next slide.
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Dr Miranda Sherley: The icy table that is actually only 10 minutes away from me so it's also very relevant to my practice and abortions are legal in the ICT.
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Dr Miranda Sherley: But after 16 weeks, they would really only be performed at the camera hospital and so, in fact, access after 16 weeks is dependent on negotiating that referral with them.
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Dr Miranda Sherley: similar to the new South Wales situation places in the ICT that provide abortion services can apply for a protest exclusion zone next slide.
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Dr Miranda Sherley: Victoria is quite similar again abortions are legal up 24 weeks and later if a second doctor grades like new South Wales people performing or assisting abortion must be qualified or risk criminal prosecution.
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Dr Miranda Sherley: Conscientious objectors must provide an alternative option, and there is again 150 major exclusion zone next slide.
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Dr Miranda Sherley: In Tasmania abortions illegal up to 16 weeks and later if a second doctor agrees those involved must be qualified conscientious objectors must provide an alternative, and they can't refuse if it's an emergency.
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Dr Miranda Sherley: Meaning that the mother's life is at risk, or that there is a risk of serious physical injury, again, there is a 150 meter exclusion zone available.
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Dr Miranda Sherley: In South Australia amy was just telling me the laws are in a state of change, so they will want to they were the first state, in fact, to legalize abortion in some situations and that's why these.
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Dr Miranda Sherley: Rules around abortion in South Australia look quite old fashioned compared to the other states, because they were very early so according to the current legal situation.
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Dr Miranda Sherley: I may be wrong on this according to me, but I thought that abortion was legal up to 23 weeks.
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Dr Miranda Sherley: Certainly the people involved must be qualified and there is a requirement that the health of the child, or the mother is at risk.
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Dr Miranda Sherley: To doctors both have to agree and the person has to have lived in South Australia for two months before the abortion can take place and the penalty for an illegal abortions very high in South Australia its life imprisonment next slide.
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Dr Miranda Sherley: In why abortion is legal up to 20 weeks, but the patient has to be over 16 or a parent or the courts must give consent on their behalf.
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Dr Miranda Sherley: After 20 weeks barrier for abortion is higher than most of the other states, it requires to other doctors from a panel that's appointed by the Health Minister to support that decision.
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Dr Miranda Sherley: And again, there needs to be a risk to the pregnant person, and there are significant penalties for unlawful abortions next slide.
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Dr Miranda Sherley: The Northern territory has the lowest gestational age for abortion at 14 weeks motions can be carried out up to 23 weeks, with the approval of the second doctor, but only in life, threatening situations.
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Dr Miranda Sherley: Next slide.
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Dr Miranda Sherley: In Queensland abortions illegal to 22 weeks gestation, and after that, with agreement from second doctor again conscientious objectors must provide an alternative option.
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Dr Miranda Sherley: And that's my quick tour of the laws around Australia let's play human face to this.
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Dr Miranda Sherley: Christine is a 19 year old student with a hospitality job on the side, she missed her period, three weeks ago she's usually regular she and her boyfriend want to terminate the pregnancy she's never been pregnant before the grandmothers come with her today as a support person next slide.
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Dr Miranda Sherley: Julie, on the other hand, has been pregnant before and at 46 she really doesn't want another child she knows her family, not a greater than abortion, she hasn't told them she's worried because she has a negative blood group.
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Dr Miranda Sherley: Next slide.
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Dr Miranda Sherley: Sally does want to be pregnant and it's actually seeking a pregnancy, through a fertility service but she's unexpectedly pregnant.
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Dr Miranda Sherley: To the wrong person to someone she really does not want to be the father of her child so she wants an abortion doesn't want him to know and then she wants to go back to the fertility service to achieve a pregnancy, as soon as possible.
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Dr Miranda Sherley: Hopefully, those three women will help provide some food for thought, while we brainstorm some of the barriers that can come into play for people seeking a termination.
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Dr Miranda Sherley: Like to take a few minutes to century some ideas, using the chat function and then we're going to have a look catch those barriers that we've come up with between us and maybe some strategies for working around some of them.
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Dr Amy Moten: But random while we're waiting, there were just a couple of specific question.
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Dr Amy Moten: In who is an equal to 16 user over 16 years.
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Dr Miranda Sherley: Ah, good question i've just got a abortion or handout next to me, so let me see if I can find the answer to that so that was in who.
00:25:38.340 --> 00:25:38.880
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Dr Miranda Sherley: At least 16 years of age.
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Dr Miranda Sherley: 16 and dog.
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Dr Amy Moten: Okay, and second question someone's just a little bit anxious, they were practicing in new South Wales and didn't weren't aware of the notification requirements it's been more than a month since the.
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Dr Amy Moten: data is there anything that can be done at this point, do you think that's a legal question, so I know that.
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Dr Miranda Sherley: I would say, other than submitting the form late and you could submit it on paper.
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Dr Miranda Sherley: know that it is a requirement is mandatory that the that those forms are submitted, and it was part of the agreement to allow abortions when those laws were passed.
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Dr Amy Moten: yeah I think South Australia is the only other State to have a form to fill out, which is actually again provide a great data for future use.
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Dr Miranda Sherley: Alright, well, I think it might be about time to start moving on and talking about these sorts of barriers that people are brought up and.
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Dr Miranda Sherley: I think there's a lot of consistency in the issues that people are raising i'm just going to shut the chat window on the side of my screen and hit back in.
00:27:07.830 --> 00:27:10.440
Dr Miranda Sherley: Or if we could move on to the next slide please.
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Dr Miranda Sherley: Alright, when I was thinking about these sorts of barriers, I tried to group them into general categories.
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Dr Miranda Sherley: And as you can see the sort of broad ideas that I came up with were issues to do with the patient and their local community and family around stigma and shame and embarrassment and self blame and fear and pressures.
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Dr Miranda Sherley: There is also sometimes issues with disagreement within an actual relationship, the the couple themselves, they can be real problems with privacy, both in terms of consultations, but also somewhere safe to have a termination.
00:27:58.440 --> 00:28:10.080
Dr Miranda Sherley: And I think it's really important to acknowledge that some people don't get a lot of control over their reproductive decision making and so that can be.
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Dr Miranda Sherley: Both control over contraception control over access to medical appointments and things like a termination and also financial control that's going to come into the cost as an area that we're going to talk about in a moment next slide please.
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Dr Miranda Sherley: So cost is something that a lot of people attending tonight raised, and it is a real issue.
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Dr Miranda Sherley: I guess the costs do very around place to place and they vary significantly between medical and surgical terminations.
00:28:43.860 --> 00:29:01.080
Dr Miranda Sherley: In my region you're probably looking at about $700 for a surgical termination and you're often looking at about four or $500 for medical termination So these are big costs, particularly for young people like our first case, the 19 year old student with a CAFE job.
00:29:02.190 --> 00:29:07.230
Dr Miranda Sherley: But there are ways we can try and keep people's costs down.
00:29:09.330 --> 00:29:17.760
Dr Miranda Sherley: Other accessibility issues that are important are that timing is a really, really important one, if you think that.
00:29:18.120 --> 00:29:29.460
Dr Miranda Sherley: If you find out you're pregnant at say five weeks a week after your periods late you that only leaves you with four weeks to get absolutely everything done and sorted before medical termination ceases to be an option.
00:29:30.240 --> 00:29:37.170
Dr Miranda Sherley: And every visit has a potential cost and every visit is someone else who knows so every visit as another possible breach of privacy.
00:29:39.420 --> 00:29:52.260
Dr Miranda Sherley: Doctors cost themselves can be a barrier to you know I Is anyone trained where you live, do they feel confident enough to offer the service or they themselves afraid of social or legal.
00:29:53.910 --> 00:29:58.980
Dr Miranda Sherley: implications of offering this service, so they repercussions for them in their community.
00:29:59.670 --> 00:30:16.410
Dr Miranda Sherley: Are they just worried about dealing with complications and providing a safe service and they themselves adequately supported by the surrounding health services so pharmacy to refer people to to get the medication and what if surgical follow up as needed.
00:30:17.520 --> 00:30:18.330
Dr Miranda Sherley: Next slide.
00:30:22.620 --> 00:30:33.810
Dr Miranda Sherley: Those issues can be exacerbated in rural and regional settings and in particular the issues around availability of services and availability of timely appointments.
00:30:35.130 --> 00:30:39.930
Dr Miranda Sherley: So what can we do to try and address these barriers i'm not going to talk about the law here.
00:30:41.010 --> 00:30:48.240
Dr Miranda Sherley: i'm just going to focus in on the areas that are more within our control as medical professionals next slide place.
00:30:49.830 --> 00:30:59.460
Dr Miranda Sherley: Starting with stigma and that sense of autonomy, I think, if you provide a welcoming space to your patients and your patients know that you're going to support them.
00:31:00.090 --> 00:31:10.620
Dr Miranda Sherley: That removes one of the biggest barriers, the first consultation is a good opportunity to explore with patients what things they perceive as being barriers.
00:31:11.370 --> 00:31:21.030
Dr Miranda Sherley: And in terms of timing and patient flow issues, there are a few different strategies to address that some services provide specific clinics for pregnancy options.
00:31:21.540 --> 00:31:27.750
Dr Miranda Sherley: On set dates some use a labeling system so patients can notify the nature of their appointment when they book.
00:31:28.650 --> 00:31:35.160
Dr Miranda Sherley: Some hold emergency appointments each day that can be used for time sensitive appointments like these.
00:31:35.820 --> 00:31:50.220
Dr Miranda Sherley: At our service if the reception style for other GPS know that someone wants to see me to discuss a termination they raise that with me directly, so I can try and find a time to fit that person as soon as possible next slide.
00:31:52.500 --> 00:32:02.640
Dr Miranda Sherley: In some areas, there may be a no cost or low cost abortion services such as public sexual health clinics, I think it's worth knowing what's available in your own region.
00:32:03.510 --> 00:32:18.090
Dr Miranda Sherley: Failing that it is worthwhile knowing what the costs are through other local services so that you can have a good discussion with your patients and they can make an informed decision, particularly about the relative pros and cons of surgical versus medical abortion.
00:32:19.230 --> 00:32:33.450
Dr Miranda Sherley: You can find out which local pharmacies can supply Ms to step and, in fact, you can lobby your own local pharmacy and say look why don't you do training we're thinking of offering the service if you train them will send people to you for the medication.
00:32:34.680 --> 00:32:45.090
Dr Miranda Sherley: You do have the ability to choose to Bob bill your own costs and we'll talk a little bit about more about medicare in a moment to look at how to make that as good as possible.
00:32:45.750 --> 00:32:55.290
Dr Miranda Sherley: And you can ask the pathology to be bought build and the medication silver's PBS so that means its price CAP which leaves the cost of imaging.
00:32:56.370 --> 00:33:06.540
Dr Miranda Sherley: You could try to negotiate an agreement, the local service to bolt bill dating ultrasounds or to bought bill that your request the local hospital might be an option.
00:33:07.650 --> 00:33:13.080
Dr Miranda Sherley: And you could consider an ultrasound for your practice and training in pregnancy dating.
00:33:13.890 --> 00:33:24.840
Dr Miranda Sherley: The units are a lot smaller and more affordable now and you might depending on your location actually even be able to claim medicare rebates for some imaging so i'm, particularly the more regional and rural.
00:33:26.010 --> 00:33:28.320
Dr Miranda Sherley: practices that is worth having to think about.
00:33:30.030 --> 00:33:33.810
Dr Miranda Sherley: Okay, moving on to medicare next slide please.
00:33:35.550 --> 00:33:40.830
Dr Miranda Sherley: You can use the standard time to consultation item numbers for these visits.
00:33:41.640 --> 00:33:54.990
Dr Miranda Sherley: But you can also use the mental health Item number if that's appropriate new spending more than 20 minutes you could use the group counseling numbers, think about our case, who comes with her grandmother if.
00:33:55.560 --> 00:34:03.960
Dr Miranda Sherley: If they come with their partner, you know if there is more two or more people and you spend an hour more than those numbers are available.
00:34:04.350 --> 00:34:15.600
Dr Miranda Sherley: there's also a specific number for non directive pregnancy counseling if you've done training and you can have up, you can use that number up to three times for the same patient.
00:34:18.150 --> 00:34:21.360
Dr Miranda Sherley: Next slide place importantly.
00:34:23.190 --> 00:34:31.440
Dr Miranda Sherley: If you are making phone or video appointments for a sexual health consultation, the usual.
00:34:33.510 --> 00:34:51.420
Dr Miranda Sherley: have to have same patient within the last 12 months face to face rule is waived, and not only do they not have to be your regular patient but longer appointments are available than are normally available abusing the phone consultation numbers.
00:34:53.790 --> 00:34:54.870
Dr Miranda Sherley: Next slide please.
00:34:56.790 --> 00:35:10.470
Dr Miranda Sherley: The script for MS to step is, as I said before, PBS authority script so you can phone or you can use proto to authorize that script and when you do, you have to confirm that you meet the authority criteria for it.
00:35:12.030 --> 00:35:12.960
Dr Miranda Sherley: Next slide.
00:35:15.360 --> 00:35:28.410
Dr Miranda Sherley: So hopefully this webinar itself and the one that's coming up next our guide go some way towards improving your confidence, you can also do mst step training, you can join all caps.
00:35:28.980 --> 00:35:41.760
Dr Miranda Sherley: You can refer to the Australian therapeutic guidelines which have a very thorough section on medical terminations or the Australian prescriber article That summarizes those therapeutic guidelines resources.
00:35:42.840 --> 00:35:51.570
Dr Miranda Sherley: Your local family planning Center might be able to provide you with support and your local sexual health service might also be able to provide you with support.
00:35:53.370 --> 00:36:01.890
Dr Miranda Sherley: I think that knowing what to expect and planning ahead are really the key to feeling confident with this next slide please.
00:36:04.050 --> 00:36:13.290
Dr Miranda Sherley: So when i'm talking to patients about complications, I give them something to take home written advice on when should I seek help.
00:36:13.800 --> 00:36:20.010
Dr Miranda Sherley: And contact numbers that they can call, but the most useful one for all of those is the one I put on the first point here.
00:36:20.760 --> 00:36:34.920
Dr Miranda Sherley: If there weren't any reason they can call the Ms to step support line it's available 24 hours a day, and there are trained nurses, on the other end of the phone who are just taking calls about medical terminations.
00:36:37.500 --> 00:36:47.550
Dr Miranda Sherley: Somebody some services, as I said, do provide a letter for the patient to take with them if they have to go for hospital, but I guess you have to have a look at your local situation, because if you.
00:36:47.820 --> 00:36:55.650
Dr Miranda Sherley: live somewhere where you really think those patients are just going to get negative judgment if they turn out to the local emergency department, saying that they.
00:36:56.520 --> 00:37:06.030
Dr Miranda Sherley: had taken medication for medical abortion, then another option is to turn up to a hospital and say that they were pregnant and I think they're having a miscarriage.
00:37:08.220 --> 00:37:09.270
Dr Miranda Sherley: Next slide please.
00:37:13.980 --> 00:37:31.320
Dr Miranda Sherley: Heavy blood loss is the main reason that people will present to a hospital but unmanageable pain or symptoms suggesting a mistake topic pregnancy are also other reasons for presenting to hospital so most of this is about the heaviness and amount of blood loss.
00:37:32.580 --> 00:37:33.270
Dr Miranda Sherley: Next slide.
00:37:35.430 --> 00:37:53.070
Dr Miranda Sherley: retained products or a suspected continued pregnancy, all the complications that are most likely to end up coming back to the general practice setting and can hopefully be handled internal practice there, the reason why we have to schedule a follow up appointments.
00:37:54.090 --> 00:37:58.320
Dr Miranda Sherley: A medical term nation wants it started does have to be seen through.
00:38:00.180 --> 00:38:10.020
Dr Miranda Sherley: Both issues retain products and continued pregnancy can be confirmed with repeat ultrasound and the beach race EG next slide place.
00:38:11.850 --> 00:38:31.770
Dr Miranda Sherley: For retail products repeat misoprostol mail our completion or the patient might go on to native dnc for continued pregnancy ever paid course of Ms to step may completely abortion or again a day and say might be needed so essentially if you think someone still has.
00:38:32.970 --> 00:38:43.950
Dr Miranda Sherley: retained products slash and ongoing pregnancy, as long as they're within 63 days you can ring up and get a second screwed famous to step and go again.
00:38:45.270 --> 00:38:52.110
Dr Miranda Sherley: And then, if you're still unhappy you're at the point where you probably need to go to referring them on for a dnc whether that's.
00:38:52.680 --> 00:39:03.090
Dr Miranda Sherley: With a gynecologist that you've got an agreement with whether that's through your local public hospital, whether they turn up to the emergency department, with or without that letter.
00:39:04.200 --> 00:39:05.010
Dr Miranda Sherley: Next slide.
00:39:06.630 --> 00:39:19.260
Dr Miranda Sherley: The other major complication is infection and really fundamentally this is best prevented so firm instructions about trying to minimize the risk of infection during the.
00:39:19.620 --> 00:39:25.560
Dr Miranda Sherley: Medical termination and immediately afterwards, but it's managed with antibiotics if it occurs.
00:39:26.010 --> 00:39:32.430
Dr Miranda Sherley: Depending on the person's STI risk and whether you did that screening back at the beginning, you might manage it using the.
00:39:32.670 --> 00:39:45.810
Dr Miranda Sherley: STI P ID guidelines or you might manage it using the post gynecological surgery P ID guidelines or intimate writers guidelines, but essentially it all comes down to choice of antibiotics.
00:39:47.040 --> 00:39:51.240
Dr Miranda Sherley: And that brings us to the end of the slide slide prepared.
00:39:52.170 --> 00:40:06.600
Dr Miranda Sherley: we've gone through the watch medical abortion is in the Australian context we've looked at barriers and we've looked at some strategies to work around those with covered the laws as they currently are across Australia.
00:40:07.140 --> 00:40:17.520
Dr Miranda Sherley: And we've looked, particularly at some of the issues in a rural and regional setting and we've still got 15 minutes or so, to talk and answer some questions.
00:40:21.240 --> 00:40:31.620
Dr Amy Moten: Excellent well done read a really thorough and comprehensive presentation there's a lot of questions which is fantastic, I think I might just start with them.
00:40:32.040 --> 00:40:46.410
Dr Amy Moten: There are a couple of questions around data and you need not to sound if there's no accurate l m P, but also what do you do to ensure that the abortion has been completed, for example, a quantitative beta hcg or an ultra sensitivity urine test.
00:40:46.590 --> 00:40:47.490
Dr Miranda Sherley: yeah those are those are.
00:40:47.520 --> 00:41:03.000
Dr Miranda Sherley: really good questions so let's start with dating you could date from the last period and have a look at a quantitative beat hcg but neither of those things are going to tell you that the pregnancy is in for us right.
00:41:03.510 --> 00:41:17.340
Dr Miranda Sherley: So essentially you're really stuck with an ultrasound to be able to confirm that you've got an entry user on pregnancy and not an ectopic, and that is one of the requirements when you ring up to get that authority script that you say it's an entry use Ryan pregnancy.
00:41:18.630 --> 00:41:31.620
Dr Miranda Sherley: So, yes i've just noticed the thing about why his shoulder to paint a red flag it's a red flag, because it might suggest an ectopic but if we've done an ultrasound at the beginning, hopefully we haven't missed an ectopic so that's not going to be a problem.
00:41:32.700 --> 00:41:40.410
Dr Miranda Sherley: So the second part of that question was around, how do we know that the terminations completed so.
00:41:41.190 --> 00:41:54.270
Dr Miranda Sherley: If we have to beat he days a week, apart, there should be an 80% drop in the beta hcg and that's why the timings really important the first one needs to be the day of them if priests down so that we can be confident that.
00:41:54.930 --> 00:42:01.140
Dr Miranda Sherley: The numbers have gone down if we take it too early, the numbers would have gone up again before they took the tablets and then.
00:42:01.680 --> 00:42:12.390
Dr Miranda Sherley: we're looking at them coming down, we may not see the true drop, and we might worry ourselves unnecessarily, you can use a low sensitivity pregnancy test.
00:42:13.290 --> 00:42:22.170
Dr Miranda Sherley: But not a high sensitivity pregnancy test and being able to confirm that you've got the right kits and there is insensitive enough to.
00:42:22.560 --> 00:42:38.310
Dr Miranda Sherley: not keep telling people they're pregnant weeks after their termination is, I think the challenge there but yes, if access to pathology services is limited, and you can get low sensitivity pregnancy tests, you can use those.
00:42:39.870 --> 00:42:45.420
Dr Amy Moten: I don't believe they're a little bit more expensive than the standard what we have in our general dp rooms.
00:42:45.990 --> 00:42:55.500
Dr Miranda Sherley: yeah I think it's mostly an access issue finding a supplier and getting them and keeping them in date if you're going to stop them yourself all of those sorts of various.
00:42:57.120 --> 00:43:07.620
Dr Amy Moten: Great Thank you and we'll set a number of likes for the question around the the 63 day or the nine week cutoff is it arbitrary, can you go beyond that.
00:43:08.430 --> 00:43:26.430
Dr Miranda Sherley: Now you can't go beyond that, because it's not license to use beyond plan so if you were a hospital and you are not stuck to the PBS rules, and if you were not, I suppose, worried about these questions about.
00:43:28.800 --> 00:43:34.410
Dr Miranda Sherley: Sticking within legislation, then you might have some flexibility.
00:43:34.830 --> 00:43:47.670
Dr Miranda Sherley: And there are certainly studies look overseas, in particular, looking at use beyond 63 days, but in Australia it's licensed for use up 63 days and not beyond.
00:43:48.030 --> 00:43:56.310
Dr Miranda Sherley: We should look at the other end as well because there's also a push for more use in very early pregnancy as well.
00:43:56.850 --> 00:44:01.620
Dr Miranda Sherley: Because of course if someone's really, really early if they've just had.
00:44:02.100 --> 00:44:09.510
Dr Miranda Sherley: Sex that they didn't use any contraception for or they're right on the date when they period would be to.
00:44:09.810 --> 00:44:18.810
Dr Miranda Sherley: it's probably too early for an ultrasound to show that pregnancy and confirm the pregnancy So what do we do then we say oh it's too soon you've got to wait two weeks, and then go and have an ultrasound.
00:44:19.290 --> 00:44:33.360
Dr Miranda Sherley: Or do we consider using the medication and again at the moment it's hard to meet the requirements of confirming that it's an entry use RON gestation until you've got five or six weeks yeah.
00:44:34.110 --> 00:44:45.960
Dr Amy Moten: And with the quantitative beta he do we just had a question doesn't need to go down below certain point post termination or drop by greater than 80%, which is, I think the standard cut off.
00:44:46.950 --> 00:44:54.780
Dr Miranda Sherley: So it really needs to drop by 80% at one week, if you follow it on over time you'll see it continuing to drop.
00:44:55.740 --> 00:45:06.120
Dr Miranda Sherley: The only reason we really do serial ones is if there's any doubt that that termination is completed, I mean that might be ongoing thing bleeding, for example.
00:45:06.840 --> 00:45:21.600
Dr Miranda Sherley: All the things that if we were dealing with a miscarriage that would make us think I think this is an incomplete miscarriage I need to keep monitoring it and you're probably going to in that situation combine it with another ultrasound as well.
00:45:23.280 --> 00:45:28.380
Dr Amy Moten: right there also, I think, quite a few questions around the racist negative status.
00:45:28.440 --> 00:45:32.310
Dr Miranda Sherley: So yes, I am sorry i'll put that in there on purpose.
00:45:32.850 --> 00:45:35.820
Dr Miranda Sherley: Because I wanted to raise it and then I asked him straight past it.
00:45:36.240 --> 00:45:58.710
Dr Miranda Sherley: So in fact guidelines for changed during the code lockdown period because it was seen as a real barrier to people accessing medical terminations and the current guidelines from the Red Cross flood service say that he for a medical termination within 10 weeks there is no need for mtd.
00:45:59.760 --> 00:46:08.940
Dr Miranda Sherley: Interestingly, they do still have a need for anti Dave miscarriages so the people turning up the hospital saying we're having a miscarriage my role still get anti day.
00:46:09.480 --> 00:46:26.580
Dr Miranda Sherley: And I thought it was a good opportunity to point out, people who was worried about anti day that you can actually register and keep a supply of antibody in your practice fridge, which is what our practice used to do before that recommendation was changed.
00:46:28.800 --> 00:46:33.630
Dr Amy Moten: The general you can refer them into a publicly do count you for entity if they needed.
00:46:34.440 --> 00:46:43.380
Dr Miranda Sherley: Yes, so, in fact, there are lots of options here, so I you know I should say again they don't need mtd if they're having a medical termination within 10 weeks.
00:46:43.680 --> 00:46:49.980
Dr Miranda Sherley: But in any situation where people do need to enter day or if they just really insistent know, I was told I need and TD.
00:46:50.550 --> 00:47:01.410
Dr Miranda Sherley: Then you can send them to an emergency department, where they can get and today there you can keep a stock of anti data in your fridge if you so desire and arrange that with the blood bank.
00:47:02.010 --> 00:47:18.930
Dr Miranda Sherley: Or you can do what I did once and ring up your local service that provides medical terminations and say oh i've got someone who really need some anti day, is there any chance you can help them provide some so it's about knowing who your local contact contacts are and.
00:47:20.010 --> 00:47:21.780
Dr Miranda Sherley: Seeing what support they can provide you.
00:47:23.190 --> 00:47:29.430
Dr Amy Moten: And that's interesting because the next question is just come through do we still need to check blood group if we no longer need add.
00:47:29.850 --> 00:47:35.730
Dr Miranda Sherley: No, we don't do we so we don't really need in the absolute.
00:47:37.080 --> 00:47:42.210
Dr Miranda Sherley: Minimum setting we really only need an ultrasound.
00:47:43.590 --> 00:47:48.960
Dr Miranda Sherley: DVD be helpful to have full blood count, so we know that they're not anemic because that's a relative country indication.
00:47:49.530 --> 00:47:53.070
Dr Miranda Sherley: It would probably be nice to know that the liver and kidney function, a good.
00:47:53.490 --> 00:47:58.260
Dr Miranda Sherley: If they do have a heavy bleeding they're going to need a transfusion it's nice know what their blood group is.
00:47:58.530 --> 00:48:12.510
Dr Miranda Sherley: But if they need a transfusion they're going to take large and they're going to cross match that blood at the time that they need the transfusion so you don't really need all of the things that you could order you really only need that ultrasound.
00:48:14.220 --> 00:48:14.970
Dr Amy Moten: Absolutely.
00:48:15.210 --> 00:48:15.750
I mean again.
00:48:21.390 --> 00:48:27.960
Dr Amy Moten: So we've had a comment in the Q amp a the biggest barrier for GPS is social repercussions which I think we both agree on.
00:48:28.650 --> 00:48:36.300
Dr Amy Moten: We need to unite can we have a platform for solidarity, well, I would like to say that asked caps would be a platform and absolutely get on there.
00:48:36.660 --> 00:48:44.400
Dr Amy Moten: Because that's end the session, as they work through everything up because that's where we can at least communicate with each other, even if we're not an advocacy group.
00:48:53.430 --> 00:49:06.930
Dr Amy Moten: So i'm just scrolling through some of the other questions and there was a question about adoption, I wonder, on your perspective there right back at the beginning, is it because you pointed out, adoption is one of the potential outcomes for an unintended pregnancy.
00:49:06.960 --> 00:49:15.930
Dr Amy Moten: what's them what's your sort of understanding in terms of how often does it happen, and is it a valid thing that people still do these days.
00:49:16.170 --> 00:49:26.100
Dr Miranda Sherley: No it's absolutely a valid thing that people still do, and that is a service that's available I don't think people realize that it's a service that's available.
00:49:26.700 --> 00:49:37.290
Dr Miranda Sherley: And that there are lots of people out there who want to adopt children who often go overseas to adopt children because it's so difficult to find children.
00:49:37.830 --> 00:49:51.210
Dr Miranda Sherley: Who are for adoption within Australia, but there are adoption services and again their state and territory, specific and some of the rules around adoption, you know.
00:49:53.070 --> 00:50:05.640
Dr Miranda Sherley: There might be a period, a cooling off period, essentially for parents to change their mind there will be rules around and knowing who your birth parents are.
00:50:06.600 --> 00:50:17.040
Dr Miranda Sherley: Access those sorts of things you so you need to find out who the local services and what the local rules around adoption are um.
00:50:17.580 --> 00:50:18.900
Dr Amy Moten: yeah I think i'd add to that.
00:50:20.430 --> 00:50:23.250
Dr Amy Moten: Instead of full adoption, we often see fostering.
00:50:23.550 --> 00:50:25.170
Dr Amy Moten: Many family fostering.
00:50:25.230 --> 00:50:35.370
Dr Amy Moten: As more of a likely option, so you know, maybe now to your grandma is willing to take on that child and then there's the option for the parents to be involved.
00:50:36.810 --> 00:50:43.770
Dr Miranda Sherley: yeah i'd agree that that's probably more common option and definitely one of the options that is available as well.
00:50:45.900 --> 00:50:48.390
Dr Amy Moten: So it's good because it's particularly Poignant.
00:50:49.020 --> 00:51:02.250
Dr Amy Moten: How do we advertise in the GB clinic to say that we perform medical termination because they're worried about protesters and of course there's some states have safe access but what's your thoughts and, in fact, as a provider, what do you do.
00:51:03.180 --> 00:51:16.380
Dr Miranda Sherley: I think it is really difficult, and I think that you've got to you know, have a chat to the other GPS in your practice as well, and try and come up with an agreement about what everyone is happy with.
00:51:18.150 --> 00:51:34.290
Dr Miranda Sherley: You might directly advertise on your practice site, you might let other local services know people who might on refer patients to you, I know some people do it that way.
00:51:35.730 --> 00:51:47.730
Dr Miranda Sherley: There are for people who've got health pathways in the region, you could get yourself listed on health pathways as well that, again, is more for other providers to be able to find you than it is for patients to be able to find you.
00:51:48.180 --> 00:52:09.240
Dr Miranda Sherley: And if you register with Ms to step, then when people have a look on the Ms two step website, they can find you and pharmacies and other providers through that Ms to set website as well and I presume all caps also is an excellent way for people to link up with services as well.
00:52:11.670 --> 00:52:14.130
Dr Amy Moten: Yes, other question.
00:52:15.390 --> 00:52:28.350
Dr Amy Moten: A few junior doctors, I think, by junior I think I mean our demos and JP registrar's just wondering about the training for image to step I believe any registered health professional or any registered medical practitioner can.
00:52:28.890 --> 00:52:32.070
Dr Amy Moten: sign up for that better need to be fully qualified pillars, do they.
00:52:32.490 --> 00:52:40.260
Dr Miranda Sherley: No, not at all and it's not too onerous it's a little bit time consuming but it's only a couple of hours really.
00:52:41.790 --> 00:52:51.420
Dr Miranda Sherley: And then you have to keep that qualification, as it were up to date, so it lasts for a couple of years and then you have to do a refresher yeah.
00:52:53.010 --> 00:53:03.000
Dr Amy Moten: And I just got another message through to saying the top docs down under on Facebook, is an excellent results, and that is correct, I haven't got around to sign up to Facebook.
00:53:04.710 --> 00:53:09.690
Dr Amy Moten: name but who definitely encourage people to join the group it's Australia wide.
00:53:14.820 --> 00:53:32.160
Dr Amy Moten: So I think we're coming up to the end of the webinar if there are any outstanding questions, I think there are quite a few around the ultrasound questions and again the earliest that you would do a m top just reinforce that for us.
00:53:32.310 --> 00:53:48.210
Dr Miranda Sherley: hmm, so I think the real reason that we need that ultrasound is for dating because we need and for showing that the pregnancy is in previews for on because you get both of those questions answered with the one thing with the ultrasound.
00:53:49.650 --> 00:53:59.460
Dr Miranda Sherley: The timing is important, with the ultrasound because you're not really going to see a very early pregnancy, so you can't really do an ultrasound before about five weeks.
00:53:59.970 --> 00:54:07.980
Dr Miranda Sherley: But five to six weeks is probably ideal timing for the ultrasound so some came see you, and they were very early in pregnancy.
00:54:08.310 --> 00:54:18.090
Dr Miranda Sherley: You might actually delay that ultrasound because it's gonna be very stressful for them to go in and be told I could i'm not sure come back again in one week we'll come back again in two weeks.
00:54:19.710 --> 00:54:22.740
Dr Amy Moten: The traveling traveling from other country town.
00:54:23.310 --> 00:54:35.580
Dr Miranda Sherley: yeah particularly so we're really going to be aiming to carry out that medical termination somewhere between five weeks when we can first get an ultrasound that's reliable.
00:54:35.940 --> 00:54:48.480
Dr Miranda Sherley: And nine weeks, which is the point at which the product is licensed to be used for medical terminations so it's really a four to five week window yeah.
00:54:50.100 --> 00:55:00.420
Dr Amy Moten: i'll just wrap up a couple of questions over a few questions about hospital emergency departments, though they do not provide terminations please don't refer to an emergency department.
00:55:00.870 --> 00:55:06.270
Dr Amy Moten: because, unfortunately, not only will they're not provide it, but they're likely to deal with a lot of stigma there.
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Dr Amy Moten: Again, if you can do the image to step training and find a registered nurse practitioner in your area another really good question do registered nurses have to do any courses at the moment emory and I believe it's not legal for registered nurses or midwives, to provide AMA.
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Dr Miranda Sherley: I think in some specific locations and I think the AC T nurse practitioners can start again it's a state and territory specific one but yes, you have to have done training.
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Dr Miranda Sherley: And you definitely shouldn't go by my word on is it or isn't it a thing in the ICT should definitely check.
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Dr Miranda Sherley: It i'm just coming back to that emergency department yeah I think that's one of the biggest concerns that people have raised with me over the years is that if you go to the emergency department with retain product so heavy bleeding after medical abortion.
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Dr Miranda Sherley: They you're going to face a whole lot of judgment from the staff there, and unfortunately I think that is true in a lot of places and it's the reason why I don't give people a lot of the emergency department.
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Dr Miranda Sherley: But some services do have arrangements with a local emergency and have negotiated for there to be a streamlined process, and so, in some areas that does work, I think it just depends.
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Dr Miranda Sherley: On your own area and the relationship, you have with your own hospital I tell people to turn up and say they're having a miscarriage.
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Dr Amy Moten: I totally agree the medical management is no different they don't need to know anything extra just that you've been pregnant no you're bleeding.
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Dr Amy Moten: So yes, oh, thank you for that, I think, will bring that to a close it clear if you can bring the next slide forward.
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Dr Amy Moten: So again, we would just like to reinforce them the the wonderful was cabinets work it's it's great to have a collaborative network where health professionals can.
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Dr Amy Moten: join up online, there are a number of different Facebook pages and things, but this is an Australia wide national.
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Dr Amy Moten: By joining us caps, you can connect and chat with like minded peers put questions to expert clinicians find providers in your area, which is one of the key things with same tonight.
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Dr Amy Moten: Good local networks and keep up to date with the latest resources and training and again happy for the rsvp specific interest group to continue collaborating with us CAP for this wonderful series of webinars and hopefully future education as well.
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Dr Amy Moten: And so I think we'll bring that to a close, I thank you again right, that was a wonderful presentation and so many questions so much engagement really happy that.
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Dr Amy Moten: We had so many people joining the chat and the Q amp a and I hope that's added to your toolbox on how to even just talk about medical portion.