1. Review patient history and confirm gestational age and all completed consents before entering exam room.
  2. Introduce yourself and ask the patient’s name to confirm identity.
  3. Establish rapport, elicit and answer patient’s questions:
    1. “What questions do you have for me?”
    2. Provide reassurance and explain process to the extent that the patient desires.
  4. Give IV medications if using.
  5. Assess patient’s pain level throughout procedure.
  6. Don gloves and protective eyewear; perform bimanual to confirm uterine position and size.
  7. Prepare equipment tray and all procedure items (cannula, block, etc.); adjust table and light.
  8. Insert the speculum, evaluate, and collect samples as needed for infection screening / testing.
  9. Apply antiseptic solution to cervix, as needed.
  10. Administer paracervical block.
  11. Place tenaculum with substantial cervical purchase; close slowly. Exert gradual traction to straighten the canal.
  12. Dilate cervix to the size of cannula you will be using [gestational age in weeks (+/- 1-2 mm)]
    1. Gently and gradually explore canal, holding the dilator loosely and allowing it to rotate within the canal; the canal should have a smooth, mucosal feel.
    2. Although it may be snug; the internal os will oft “give way” to gentle, steady pressure.
    3. If unable to pass through the internal os, try the following:
      • Gently apply traction on the tenaculum with slightly greater force to straighten the canal.
      • Change angle of dilator.
      • Try flexible plastic sound or os finder.
      • Change the tenaculum location (to posterior lip for a retroflexed uterus).
      • If acutely flexed cervix, try widening the speculum blades.
      • Use transabdominal US guidance.
      • Repeat pelvic exam.
      • Consider shorter, wide speculum.
      • Provide misoprostol (sublingual/vaginal); reattempt dilation in 1.5 – 3 hrs.
  13. Insert the cannula through the cervix while exerting gentle but firm traction with the tenaculum, and advance the cannula to the fundus. Connect the aspirator to the cannula.
  14. Use manual or electric vacuum to empty the uterus until signs that it is empty (detail below).
  15. After confirming products of conception (POC) are complete, place IUD or implant if requested.
  16. Remove tenaculum, assure minimal bleeding, and remove speculum.
  17. Check for adequacy of POC, if not already done.
  18. Inform patient of complete procedure and recovery process.
prepare the aspirator

Prepare the aspirator


  • Begin with valve buttons open and
    plunger pushed fully into the barrel.
  • Close valve by pushing the buttons
    down and forward until locked in place.
Create the vacuum

Create the vacuum


  • Pull the plunger back until its arms
    snap outward over the rim at end of the barrel.
  • Make sure the plunger arms are positioned
    over wide edges of the barrel rim.
Gently dilate the cervix

Gently dilate the cervix


  • Use dilators of increasing size to accommodate
    cannula size chosen based on gestational weeks.
  • Dilator:
    • Denniston – dilate to cannula size
      (e.g. size 7 for 7 mm cannula)
    • Pratt – dilate to cannula size x 3
      (e.g. 21 French for 7mm cannula)
choose a cannula

Choose a cannula


  • Flexible: longer with two openings at tip
  • Rigid: larger single opening at tip
  • No significant difference in safety or efficacy
    (Kulier 2001)


  • Larger: faster aspiration, intact tissue
  • Smaller: less dilation and resistance


NAF Provider’s survey (O’Connell 2009):

  • 54% used size (in mm) = weeks gestation
  • 37% used 1-2 mm < weeks gestation
  • 9% used 1-3 mm > weeks gestatio
Insert the cannula

Insert the cannula


  • Apply traction to tenaculum to straighten uterus.
    Then holding cannula with fingertips, gently
    insert through cervix with rotating motion.
  • Attach aspirator to cannula.
  • Do not grasp aspirator by plunger arms.
Release the pinch valve

Release the valve buttons


  • When the pinch valve is released, the vacuum is
    transferred through the cannula into the uterus.
  • Blood, tissue, and bubbles will flow through the
    cannula into the aspirator
evacuate the uterus

Evacuate the uterus


  • Rotate the cannula and move it gently from fundus
    to the internal os, applying a back and forth motion as clinically indicated until:

    • Grittiness is felt through cannula
    • Uterus contracts and grips cannula
    • There is increased cramping, and / or
    • No more blood passes through cannula
stand Choice of Vacuum for Aspiration

  • Availability / preference determine use
  • MVA is FDA approved to 12 weeks
  • Some use > 1 MVA to facilitate emptying, or switch to EVA > 9 weeks
  • Minimal differences in pain, anxiety, bleeding, or acceptability (Dean 2003)
  • EVA sound disturbs some patients; silent, in-wall suction is available.

EVA use:

  • Attach cannula and close thumb valve
  • Place cannula into uterus
  • Turn on and check suction gauge
  • To modify: turn dial or adjust valve
  • Release suction (open thumb valve) when passing through cervical canal.
inspect tissue

Inspect the tissue


  • Rinse and strain the tissue
  • Place tissue in a clear container
  • Backlight is recommended to inspect
    tissue if gross visual inspection is non-diagnostic.
gestational sac in blue Gestational sac at 6 weeks

  • Shredded (on left) vs. intact
  • To minimize shredding, consider using MVA
    (< pressure than EVA); slightly larger cannula.
membranes and villi Membranes and Villi (POC)
Frond-like villi
Clumps held by membrane
Transparent like plastic wrap
Luminescent; light refractory
Turns white if vinegar added
More stretchy
Floats more in liquid media
Size: see coin sizes above
Decidua (not POC)
No fronds
No villi or thin membrane
Opaque like wax paper
Less light refractory
Minimal color change
More breakable
Sinks more in liquid media
Quantity variable
image Decidua capsularis
Caution not to confuse
a) gestational sac (8 week) with
b) decidua capsularis, a portion of the decidua
which grows proportionally to gestational sac
but is thicker and tougher(Image: Edwards, J).
Fetal part development
Parts may be seen earlier.
≥ 10W look for 4 extremities, spine,
calvarium and gestational sac.≥12W must find all
fetal parts + placenta

Illustrated images adapted from Manual Vacuum Aspiration, a presentation by Physicians and ARHP, 2000; 2012.


Early Abortion Training Workbook Copyright © 2016 by UCSF Bixby Center for Global Reproductive Health. All Rights Reserved.