- Review patient history and confirm gestational age and all completed consents before entering exam room.
- Introduce yourself and ask the patient’s name to confirm identity.
- Establish rapport, elicit and answer patient’s questions:
- “What questions do you have for me?”
- Provide reassurance and explain process to the extent that the patient desires.
- Give IV medications if using.
- Assess patient’s pain level throughout procedure.
- Don gloves and protective eyewear; perform bimanual to confirm uterine position and size.
- Prepare equipment tray and all procedure items (cannula, block, etc.); adjust table and light.
- Insert the speculum, evaluate, and collect samples as needed for infection screening / testing.
- Apply antiseptic solution to cervix, as needed.
- Administer paracervical block.
- Place tenaculum with substantial cervical purchase; close slowly. Exert gradual traction to straighten the canal.
- Dilate cervix to the size of cannula you will be using [gestational age in weeks (+/- 1-2 mm)]
- 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.
- Although it may be snug; the internal os will oft “give way” to gentle, steady pressure.
- 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.
- 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.
- Use manual or electric vacuum to empty the uterus until signs that it is empty (detail below).
- After confirming products of conception (POC) are complete, place IUD or implant if requested.
- Remove tenaculum, assure minimal bleeding, and remove speculum.
- Check for adequacy of POC, if not already done.
- Inform patient of complete procedure and recovery process.
|USING MVA AND EVA EQUIPMENT|
Prepare the aspirator
Create the vacuum
Gently dilate the cervix
Choose a cannula
NAF Provider’s survey (O’Connell 2009):
Insert the cannula
Release the valve buttons
Evacuate the uterus
|Choice of Vacuum for Aspiration
Inspect the tissue
|Gestational sac at 6 weeks
|Membranes and Villi (POC)
Clumps held by membrane
Transparent like plastic wrap
Luminescent; light refractory
Turns white if vinegar added
Floats more in liquid media
Size: see coin sizes above
|Decidua (not POC)
No villi or thin membrane
Opaque like wax paper
Less light refractory
Minimal color change
Sinks more in liquid media
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.