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Department of Reproductive Health and Research (RHR), World Health Organization

Managing Complications in Pregnancy and Childbirth

A guide for midwives and doctors 

 


Section 3 - Procedures


Manual vacuum aspiration

  • Review for indications (inevitable abortion before 16 weeks, incomplete abortion, molar pregnancy or delayed PPH due to retained placental fragments).

  • Review general care principles.

  • Provide emotional support and encouragement and give paracetamol 30 minutes before the procedure. Rarely, a paracervical block may be needed.

  • Prepare the MVA syringe: 

- Assemble the syringe;

- Close the pinch valve;

- Pull back on the plunger until the plunger arms lock. 

Note: For molar pregnancy, when the uterine contents are likely to be copious, have three syringes ready for use.

  • Even if bleeding is slight, give oxytocin 10 units IM or ergometrine 0.2 mg IM before the procedure to make the myometrium firmer and reduce the risk of perforation.

  • Perform a bimanual pelvic examination to assess the size and position of the uterus and the condition of the fornices.

  • Apply antiseptic solution to the vagina and cervix (especially the os).

  • Check the cervix for tears or protruding products of conception. If products of conception are present in the vagina or cervix, remove them using ring (or sponge) forceps.

  • Gently grasp the anterior lip of the cervix with a vulsellum or single-toothed tenaculum.

Note: With incomplete abortion, a ring or sponge forceps is preferable as it is less likely than the tenaculum to tear the cervix with traction and does not require the use of lignocaine for placement.

  • If using a tenaculum to grasp the cervix, first inject 1 mL of 0.5% lignocaine solution into the anterior or posterior lip of the cervix which has been exposed by the speculum (the 10 o’clock or 12 o’clock position is usually used).

  • Dilatation is needed only in cases of missed abortion or when products of conception have remained in the uterus for several days:

- Gently introduce the widest gauge suction cannula;

- Use graduated dilators only if the cannula will not pass. Begin with the smallest dilator and end with the largest dilator that ensures adequate dilatation (usually 10–12 mm) (Fig P-33);

- Take care not to tear the cervix or to create a false opening.

  • While gently applying traction to the cervix, insert the cannula through the cervix into the uterine cavity just past the internal os (Fig P-35). (Rotating the cannula while gently applying pressure often helps the tip of the cannula pass through the cervical canal.)

Figure P-35

 Inserting the cannula

  • Slowly push the cannula into the uterine cavity until it touches the fundus, but not more than 10 cm. Measure the depth of the uterus by dots visible on the cannula and then withdraw the cannula slightly.

  • Attach the prepared MVA syringe to the cannula by holding the vulsellum (or tenaculum) and the end of the cannula in one hand and the syringe in the other.

  • Release the pinch valve(s) on the syringe to transfer the vacuum through the cannula to the uterine cavity.

  • Evacuate remaining contents by gently rotating the syringe from side to side (10 to 12 o’clock) and then moving the cannula gently and slowly back and forth within the uterine cavity (Fig P-36).

Note: To avoid losing the vacuum, do not withdraw the cannula opening past the cervical os. If the vacuum is lost or if the syringe is more than half full, empty it and then re-establish the vacuum.

Note: Avoid grasping the syringe by the plunger arms while the vacuum is established and the cannula is in the uterus. If the plunger arms become unlocked, the plunger may accidentally slip back into the syringe, pushing material back into the uterus. 

Figure P-36

Evacuating the contents of the uterus

  • Check for signs of completion:

- Red or pink foam but no more tissue is seen in the cannula;

- A grating sensation is felt as the cannula passes over the surface of the evacuated uterus;

- The uterus contracts around (grips) the cannula.

  • Withdraw the cannula. Detach the syringe and place the cannula in decontamination solution.

  • With the valve open, empty the contents of the MVA syringe into a strainer by pushing on the plunger. 

Note: Place the empty syringe on a high-level disinfected tray or container until you are certain the procedure is complete.

  • Perform a bimanual examination to check the size and firmness of the uterus.

  • Quickly inspect the tissue removed from the uterus:

- for quantity and presence of products of conception;

- to assure complete evacuation;

- to check for a molar pregnancy (rare).

If necessary, strain and rinse the tissue to remove excess blood clots, then place in a container of clean water, saline or weak acetic acid (vinegar) to examine. Tissue specimens may also be sent to the pathology laboratory, if indicated. 

  • If no products of conception are seen:

- All of the products of conception may have been passed before the MVA was performed (complete abortion);

- The uterine cavity may appear to be empty but may not have been emptied completely. Repeat the evacuation;

- The vaginal bleeding may not have been due to an incomplete abortion (e.g. breakthrough bleeding, as may be seen with hormonal contraceptives or uterine fibroids);

- The uterus may be abnormal (i.e. cannula may have been inserted in the nonpregnant side of a double uterus).

Note: Absence of products of conception in a woman with symptoms of pregnancy raises the strong possibility of ectopic pregnancy.

  • Gently insert a speculum into the vagina and examine for bleeding. If the uterus is still soft and not smaller or if there is persistent, brisk bleeding, repeat the evacuation.

POST-PROCEDURE CARE

  • Give paracetamol 500 mg by mouth as needed. 

  • Encourage the woman to eat, drink and walk about as she wishes.

  • Offer other health services, if possible, including tetanus prophylaxis, counselling or a family planning method.

  • Discharge uncomplicated cases in 1–2 hours.

  • Advise the woman to watch for symptoms and signs requiring immediate attention:

- prolonged cramping (more than a few days);

- prolonged bleeding (more than 2 weeks);

- bleeding more than normal menstrual bleeding;

- severe or increased pain;

- fever, chills or malaise;

- fainting.

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Clinical principles

Rapid initial assessment

Talking with women and their families

Emotional and psychological support

Emergencies

General care principles

Clinical use of blood, blood products and replacement fluids

Antibiotic therapy

Anaesthesia and analgesia

Operative care principles

Normal Labour and childbirth

Newborn care principles

Provider and community linkages

Symptoms

Shock

Vaginal bleeding in early pregnancy

Vaginal bleeding in later pregnancy and labour

Vaginal bleeding after childbirth

Headache, blurred vision, convulsions or loss of consciousness, elevated blood pressure

Unsatisfactory progress of Labour

Malpositions and malpresentations

Shoulder dystocia

Labour with an overdistended uterus

Labour with a scarred uterus

Fetal distress in Labour

Prolapsed cord

Fever during pregnancy and labour

Fever after childbirth

Abdominal pain in early pregnancy

Abdominal pain in later pregnancy and after childbirth

Difficulty in breathing

Loss of fetal movements

Prelabour rupture of membranes

Immediate newborn conditions or problems

Procedures

Paracervical block

Pudendal block

Local anaesthesia for caesaran section

Spinal (subarachnoid) anaesthesia

Ketamine

External version

Induction and augmentation of labour

Vacuum extraction

Forceps delivery

Caesarean section

Symphysontomy

Craniotomy and craniocentesis

Dilatation and curettage

Manual vacuum aspiration

Culdocentesis and colpotomy

Episiotomy

Manual removal of placenta

Repair of cervical tears

Repair of vaginal and perinetal tears

Correcting uterine inversion

Repair of ruptured uterus

Uterine and utero-ovarian artery ligation

Postpartum hysterectomy

Salpingectomy for ectopic pregnancuy

Appendix

 

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