It is our belief that women are entitled to the best medical care available regardless of their decision to carry the pregnancy to term or to have an abortion. It is also our belief that women who choose to have an abortion should be able to have it done under circumstances that are safe, dignified, humane, confidential, and supportive of her as a person.

We know this is a difficult decision for many women and that it can be a stressful time for you. We will provide you with the help you need to come to the best choice for you. If you decide to have an abortion, our first concern is for your safety and well-being. This section will tell you about the services we provide and the steps we take to assure your safety.

SERVICES PROVIDED

• Outpatient elective abortion through 26 weeks from the last menstrual period
• Medically indicated termination of pregnancy up to 34 weeks from last menstrual period (including fetal anomalies, genetic disorder, fetal demise, or severe medical problems)
• Pregnancy testing
• Diagnostic ultrasound for determination of length of pregnancy
• Birth control counseling
• Contraceptive care
• Problem pregnancy decision counseling
• Post-abortion counseling

SAFETY
Boulder Abortion Clinic is the safest place in the world to have an abortion or to terminate a late pregnancy. Dr. Hern has been a pioneer in developing safe abortion techniques throughout the range of pregnancy in which abortions are performed. Major complication rates in patients seen at Boulder Abortion Clinic range from 0.0001% (1 per 10,000) in first trimester abortion to published major complication rates of 0.2% in later abortion - the lowest complication rates in the medical literature. This is not an accident. All procedures at Boulder Abortion Clinic are designed to maximize patient safety and good surgical technique.

Not a single patient experiencing first trimester abortion has suffered a uterine perforation during an abortion procedure begun at Boulder Abortion Clinic - a record of safety in over 30,000 first trimester patients that is unequalled in the medical literature.

A major component of this safety program is the emphasis of sound preoperative evaluation of each patient, which includes a medical history, physical examination and diagnostic ultrasound evaluation.

A second component is strict attention to good principles of surgical technique and medical management.

A third component is proper postoperative care and followup procedures to assure prompt recognition and treatment of all complications, including the most minor.

A fourth component is constant evaluation and research on ways of improving safety and other aspects of abortion care.

MEDICAL PROCEDURES
- First trimester (two day outpatient procedure)

On the first day of the first trimester procedure, each patient is given a preoperative examination with ultrasonography to determine the length of pregnancy as precisely as possible. This examination also provides the opportunity to identify any unusual or pathologic aspects of the pregnancy or pelvic structures that could affect safety. The ultrasonographic screening exam is included in the patient fee.

Routine laboratory examinations include a hematocrit (test for anemia), blood Rh type, and a basic urine test. These tests are also included in the fee.

Following a session to provide routine information necessary to giving informed consent, the patient meets with the physician (Dr. Hern) so that the doctor can answer any remaining questions, to review follow-up plans, and to review birth control methods to be used after the abortion.

The patient then receives a routine physical examination and pelvic examination by the physician. At that point, one laminaria is inserted into the cervix (opening of the uterus). The laminaria is a naturally occurring seaweed about the size of a kitchen matchstick that has the property of absorbing moisture from the body and slowly becoming larger. It has been medically prepared so as to prevent infection. After it has been placed in the cervix, the laminaria expands overnight and dilates the cervix in a gentle, natural manner that reduces pain during the procedure and reduces the risk of uterine perforation.

In addition to Dr. Hern's own experience with 30,000 first trimester abortion patients, the medical literature strongly supports the evidence that the use of laminaria reduces the trauma to the cervix and the risk of uterine perforation.

On the second day, the patient returns to the clinic for her abortion. A preoperative narcotic analgesia is provided to make the patient as comfortable as possible. The laminaria is removed, and local anesthesia is placed in the cervix in order to minimize pain. The suction cannula is then inserted into the cervix and the uterine contents removed by vacuum aspiration. When this phase is completed (about 2 minutes), the uterus is explored with other instruments that permit the physician to remove all tissue, thereby reducing the risk of complications.

The patient is observed in the recovery room for a period of up to an hour in order to observe for evidence of any complications.

The patient is then given a follow-up exam appointment unless she plans to visit her own physician or another facility for her follow-up care.

MEDICAL PROCEDURES
- Second trimester (three day outpatient procedure)

Second trimester patients also receive an ultrasound screening exam at the very beginning of their appointment at Boulder Abortion Clinic. In this case, a more extensive examination is necessary. Among those features of the pregnancy evaluated at this time include the diagnosis of fetal age, which is made by measuring various parts of the fetus, such as head size and femur length, that give a precise knowledge of fetal age. Other evaluations include position of the placenta, the presence of, absence of, or unusual quantity of amniotic fluid, the presence of visible fetal anomalies, pathology such as fibroids in the uterine wall, and whether the fetus is alive or not.

Aside from variations in the content of educational and informed consent materials appropriate for the length of gestation, the second trimester patient experiences the same preoperative procedures as the first trimester patient. The main difference is that the second trimester patient experiences an extra day of laminaria dilation of the cervix.

The second trimester patient returns on the second day for replacement of the original laminaria with several new laminaria in order to continue and enhance the process of cervical dilation. This procedure, done under local anesthesia, usually takes only a few minutes, but it is an essential step in the process to assure maximum safety.

15 To 19 Weeks

From 15 through 19 menstrual weeks, the patient comes in at her appointed time for her abortion and is given a preoperative analgesic and sedative medication. In the operating room, the laminaria are removed and the cervix checked for adequate dilation. The amniotic sac is then ruptured with instruments under direct ultrasound vision. The purpose of this maneuver is to release all the amniotic fluid to the extent possible. This prevents the patient from experiencing an amniotic fluid embolism, in which the amniotic fluid can enter the bloodstream and cause death or serious complications. Because amniotic fluid embolism (AFE) is one of the most dangerous possible complications of pregnancy and abortion, Dr. Hern developed the technique of preventing this complication from happening.

After that, the uterine contents are evacuated surgically by using forceps and other instruments placed into the uterus through the vagina and cervix. An intravenous infusion (IV) is in place at this time so that the physician can give medication quickly for pain and to give medication that causes the uterus to contract as the abortion is completed.

20 to 26 Weeks

At 20 menstrual weeks and later, the first step in the abortion procedure on the first day is an injection of medication into the fetus that will stop the fetal heart instantly. The patient is awake during this procedure, which is done under local anesthesia and with the use of direct ultrasound vision. The woman does not observe the fetus on the ultrasound screen in this process. The injection, done with strict attention to sterile technique, usually takes about ten minutes, although the appointment may take longer because of preparations that must be made.

Following the injection into the fetus, the first laminaria is placed in the cervix. The patient may leave at that time and must stay in Boulder unless arrangements are made for the patient to stay in a neighboring town. On the second day, the second trimester patient returns for a brief appointment, at which time the first laminaria is removed and more are placed under local anesthesia. This process permits maximum gentle dilation of the cervix over a two-day period.

On the third day, the patient returns for her abortion. Following observation of vital signs (blood pressure, temperature, and pulse), the laminaria are removed and a long-acting local anesthesia is again placed in the cervix. Under direct ultrasound vision, the amniotic membrane is ruptured so as to permit free flow of the amniotic fluid from the uterus. The amniotic fluid is drained as completely as possible. This maneuver has several objectives:

First, removal of the amniotic fluid reduces if not eliminates the risk of amniotic fluid embolism (AFE), probably the most dangerous possible complication of late abortion.

Second, release of the amniotic fluid allows the uterus to contract and become firm, reducing the risk of perforation of the uterus with instruments.

Third, contraction of the uterus reduces blood loss.

Fourth, release of the amniotic fluid and contraction of the uterus enhances movement of the fetus and placenta into the cervix, the opening of the uterus, thereby adding safety and reducing discomfort of the procedure.

Fifth, this maneuver permits the accurate measurement of blood loss, which is usually minimal. However, heavy bleeding may occur in late abortion, and it is absolutely necessary to know accurately the volume of this bleeding in order to guide fluid or blood replacement if this should become necessary.

As with the earlier second trimester procedures (15-19 weeks), the later second trimester procedure (20-26 weeks) may require that the physician perform a surgical evacuation of the uterus ("dilation and evacuation" or "D & C") using instuments such as forceps to remove the fetus and placenta. All the other steps taken up to that point, such as use of laminaria, induced fetale demise, and medical induction, serve to enhance the safety of the late second trimester abortion procedure. The choice of procedures is dictated by the woman's safety needs at the time.

Fewer than 1 in 2000 patients has needed a blood transfusion in second trimester and later abortions at Boulder Abortion Clinic - a remarkable record of safety, considering the fact that up to 5% of all second trimester patients have required transfusion in other clinic settings in the United States.

MEDICAL PROCEDURES
- Third trimester (three day outpatient procedure)

Patients coming in for very late abortion - over 26 menstrual weeks' gestation - are almost always seeking services for termination of a desired pregnancy that has developed serious complications. This usually means the discovery of a catastrophic fetal anomaly or genetic disorder that guarantees death, suffering, or serious disability for the baby that would be delivered if the pregnancy were to continue to term. Occasionally a woman presents at this stage for pregnancy termination because of her own severe medical illness or a psychiatric indication.

At this point, termination of pregnancy is considered a far more dangerous procedure and carries with it serious risks of complication. That is why pregnancy termination at this stage requires more experience and skill in the operating physician. It also requires scrupulous attention to procedures that reduce the risk of complication.

The first step for third trimester patients is the same as for second trimester patients at 20 weeks or more. The main difference here is that more precautions are taken to reduce the special risks for more advanced pregnancy termination.

Instead of changing the laminaria once on the second day, for example, the laminaria may be changed twice. A third day of laminaria treatment is rarely, but possibly, necessary.

One of the main differences for third trimester patients having a pregnancy terminated for fetal anomaly is that they may wish to have an intact fetus that they can examine and hold as part of the grief process. For many of these patients, it is not a fetus - it's a baby. The woman and her family may request special procedures such as special religious ceremonies, genetic studies, formal autopsy, private cremation, or private burial. We can arrange for any or all of these special procedures upon request.

While these procedures or ceremonies can be arranged upon request, we do not expect or require any patients or families to go through any special rituals, ceremonies, or grief process at Boulder Abortion Clinic. Dr. Hern believes that the patient's own family, physician, and religious counselors are better prepared to provide these kinds of support at home in most cases.

All third trimester patients are carefully observed in the recovery room for a period of up to two hours before being discharged to the care of a family physician, unless a patient desires return to Boulder Abortion Clinic for her follow-up examination.

COUNSELING
Women seeking termination of pregnancy at Boulder Abortion Clinic have highly individual needs. These needs vary widely; the pregnancy may be highly desired by the woman and her partner, but it cannot be continued because of abnormal development. The pregnancy may be desired, but it comes at the wrong time in the woman's life or in her relationship with her partner. She may not have a satisfactory, or any, relationship with the man by whom she became pregnant. Some women do not want ever to have children; many become pregnant when they are not prepared to become a mother or to have another child.

When we use the term "counseling" at Boulder Abortion Clinic, it does not mean that we expect to provide women and their families with psychotherapy or intervention. Our first concern is to provide support for the woman seeking our services. In addition to this, we wish to provide support for her family to the extent possible and appropriate.

The objective of a counseling session is to give the woman an opportunity to express and understand her feelings about her pregnancy and her decision to have or not to have an abortion. We want to determine, first, that this is really her decision and that she is not being pressured in any way to end the pregnancy.

We wish to provide the woman with solid information about the procedure she is requesting. It is important that she know and understand important facts and details in order to be able to give informed consent.

As a part of this, we wish to make sure that the woman understands her own reproductive anatomy and physiology. Most women do, but even highly educated women sometimes have misunderstandings or questions that we can answer.

We wish to help each woman understand the methods of fertility control that are available to her and her partner following the abortion. As a part of this, we want to make sure that each woman has a plan for follow-up care in order to assure that she does not experience complications and that she receives appropriate treatment if she does. We encourage each patient to see her own physician or a qualified physician in her own community for follow-up care, but we are ready to provide that care if the woman desires us to do so.

For couples who come to us with a desired pregnancy which must be terminated for reasons of fetal malformation or genetic disorder, we are prepared to give total support. However, we feel that their most satisfactory permanent support is likely to be found in their own physician or counselor in their own home community.

The women who provide counseling and information sessions for patients at Boulder Abortion Clinic are experienced nurses and counselors who are thoroughly familiar with all aspects of abortion, who are fully supportive of women who wish to terminate pregnancies, and who are able to answer most questions that arise.

After the patient reviews informational material and meets with her counselor, she meets with the physician (Dr. Hern) to conclude this phase of her experience. If she has questions that have not been answered by her counselor, she may have them answered at this time. It is at this time that she signs the consent form indicating that she understands and requests the procedure that will terminate her pregnancy. She may bring her partner or other family members with her during this encounter.

Although the woman's partner, friends, or family may accompany her during part of her counseling session and the meeting with Dr. Hern, and these persons may see her in the recovery room after the abortion, partners and family members are not permitted in the operating room.

POSTOPERATIVE CARE
Because pregnancy is not a benign condition, and because terminating a pregnancy is a surgical procedure, each patient must have excellent postoperative and follow-up care. This is absolutely necessary to prevent complications and to treat them satisfactorily if they occur. No matter how well an abortion is performed, complications can occur. The difference between a safe result with a full return to good health and an undesirable result is often good postoperative care and prompt treatment of complications.

Each patient who has an abortion at Boulder Abortion Clinic is taken from the operating room to a nearby recovery room where she can lie down, relax, and receive the attention of the recovery room nurses as well as her family members and friends. During this time, her blood pressure and pulse as well as other aspects of physical evaluation will be monitored by expert recovery room nurses. She will receive information concerning aftercare and her follow-up examination. If she has chosen a method of birth control, she may receive information or, in the case of oral contraceptives, a starting supply of these. Her vital signs (blood pressure, pulse) will be observed on several occasions after the abortion; before leaving the operating room, upon arriving in the recovery room, and before being discharged from the recovery room. The nurse makes numerous other observations of each patient such as general status, presence or absence of abdominal pain, amount of bleeding, and state of recovery from pain medications. Follow-up exams at Boulder Abortion Clinic are included in the fee for those who can and wish to return to see Dr. Hern and his staff for the follow-up exam.

Our purpose is to see that every woman who comes to Dr. Hern's office for termination of pregnancy receives the safest possible care that is thorough, humane, and supportive of her and her family. When she leaves, we want her to feel confident that she is returning to good health and that she is able to live her life as she chooses to live it.