Emergency Treatment Module 2 - Session 5 Vacuum Aspiration

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Emergency TreatmentModule 2 - Session 5Vacuum
Aspiration
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Module 2 - Session 5Objectives

• At the end of this session, participants will be
  able to
• Identify the parts of the MVA equipment and
  select correct syringe/cannula size
• If using electric vacuum (EVA) or foot pump
  vacuum (FSE) a) identify the parts of the
  electric vacuum aspirator or foot pump vacuum
  equipment, and b) select the correct cannula
  size
• Demonstrate ability to check, assemble and
  prepare equipment
• Perform the VA procedure according to the steps
  outlined
• Demonstrate appropriate counseling before, during
  and after the VA procedure
• Recognize and solve technical or procedural
  problems during VA
• Record complete, accurate case information in
  client charts, logbooks and other forms as needed

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A Word about MVA Instruments

• No single brand of MVA instruments is perfectly
  suited to every setting, and no single element of
  the instruments unequivocally identifies one
  brand as superior to another.
• However, it is evident that certain instruments
  do not meet minimum safety, functionality and
  durability standards.
• While the lowest-cost MVA instruments may appear
  most appealing ... these products may not
  necessarily be the safest or most cost-effective,
  due to their decreasing safety, functionality or
  effectiveness over time.
• Some products that cost more at the outset may in
  fact prove less expensive over the long term.
• Source EngenderHealth, 2001.

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Manual Vacuum Aspiration

• Manual vacuum aspiration (MVA) uses a specially
  designed, hand-held vacuum syringe with a
  flexible plastic cannula to apply suction in
  order to remove the products of conception from
  the uterus. This method does not require
  electricity.
• Note MVA is not the ideal procedure for
  evacuating the uterus in molar pregnancies
• The amount of tissue in such cases is often
  copious.
• Refer the patient with suspected molar pregnancy
  to a higher level of care.

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Foot Pump Suction Evacuation

• Foot pump suction evacuation (FSE) involves use
  of a foot pump suction evacuator with a flexible
  plastic cannula to obtain vacuum and perform the
  evacuation procedure, using either intermittent
  or continuous suction. This method also does not
  require electricity.

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Electric Vacuum Aspiration

• Electric vacuum aspiration (EVA) uses an electric
  pump and metal or plastic cannulae to evacuate
  the uterus by providing either intermittent or
  continuous suctioning. The cannula is inserted
  into the uterus and then attached by a tube to
  the machine. Once the machine is turned on, the
  cannula is moved around gently until all of the
  tissue of the products of conception is removed.

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MVA Instrument Labels
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Preparing VA Instruments

• Select cannulae
• Inspect cannulae for cracks or other defects
  discard if there are any visible signs of
  weakness or wear.
• Select cannulae according to the assessment of
  uterine size (weeks LMP).
• Prepare several cannulae of different sizes. The
  cannula needs to be large enough to allow passage
  of tissue expected (according to gestation) and
  fit snugly through the cervix.

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Preparing MVA Instruments (2)

• Select syringes and adapters (if needed)
• It may be useful to prepare two syringes as the
  amount of uterine blood and tissue is difficult
  to predict.
• Note that the colored dots on the cannulae match
  the color of the appropriate adapter, if
  applicable.

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Preparing MVA Instruments (3)

• Inspect syringes
• Syringe must be able to hold a vacuum. Discard
  syringes with any visible cracks or defects or
  those that do not hold a vacuum.
• Attach the adapter (if required)
• Attach to the end of the syringe or cannula. The
  MVA Plus syringe does not require an adapter.
• Check the plunger and valve on the syringe
• The plunger should be positioned all the way into
  the barrel, and the pinch valve open, with the
  valve button out.

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Preparing MVA Instruments (4)

• Close the pinch valve
• Push the button down and forward until you hear
  it lock into place.
• Prepare the syringe
• Grasp the barrel and pull back on the plunger
  until the arms of the plunger snap outward.
• Plunger arms must be fully secured over the edge
  of the barrel, so the plunger cannot move forward
  involuntarily. Incorrect positioning of the arms
  could allow them to slip back inside the barrel.
• Never grasp the syringe by the plunger arms.

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Preparing MVA Instruments (5)

• Check the syringe for vacuum tightness before
  use
• Leave the syringe for several minutes with the
  vacuum established.
• Open the pinch valveyou should hear a rush of
  air into the syringe, indicating that there was a
  vacuum in the syringe.
• Re-establish the vacuum in the syringe for use
  during the procedure.

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Preparing Electric Vacuum (EVA) or Foot Pump
Suction (FSE) Instruments

• If using electric or foot pump suction
• Select cannulae
• Inspect cannulae for cracks or other defects
  discard if there are any visible signs of
  weakness or wear.
• Select cannulae according to the assessment of
  uterine size (weeks LMP).
• Prepare several cannulae of different sizes. The
  cannula needs to be large enough to allow passage
  of tissue expected (according to gestation) and
  fit snugly through the cervix.
• Check that the EVA or FSE equipment creates a
  vacuum.

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Performing the VA Procedure Pre-Procedure Client
Care

• Rapid assessment
• Complications either ruled out or treated and
  client is stable
• Obtain client history.
• Conduct physical and pelvic exam (including
  assessment of uterine size).
• Rule out contraindications to VA.
• Review precautions, where appropriate.
• Tell the client what is happening/what to expect
  during procedure.
• Discuss pain management with the client.
• Obtain any consents required.

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Performing the VA Procedure Pre-Procedure Client
Care (2)

• Provide counseling as appropriate.
• Have client empty her bladder.
• Position and drape the client in lithotomy
  position.
• Administer pain control.
• Ensure and implement infection prevention
  measures.
• If possible, have a support person available to
  provide emotional support during the procedure.

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The VA Procedure

• Step 1 Before you start
• Drape the client in lithotomy position.
• Wash hands and put on gloves.
• Determine uterine size and position.
• Determine cervical dilatation.
• Insert a vaginal speculum.
• Swab cervix and vagina with antiseptic
  (especially the os).
• Check the cervix for tears or protruding POC. If
  products of conception are present in the vagina
  or cervix, remove using ring (or sponge)
  forceps.
• Gently apply a vulsellum or single-toothed
  tenaculum to the anterior lip of the cervix. A
  ring forceps is preferable.

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The VA Procedure (2)

• Step 2 Dilate the cervix (if needed often the
  womans cervix is already dilated).
• Step 3 Insert the cannula.
• Step 4 Measure the size of the uterus.

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The VA ProcedureIf Using MVA

• Step 5 Evacuate the uterus.
• If using MVA
• Attach the prepared syringe.
• Release the pinch valve.
• Evacuate the remaining contents of the uterus.
• Check for signs of completion.
• Detach syringe and remove all instruments.
• Step 6 Inspect the tissue removed from the
  uterus.

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The VA ProcedureIf Using EVA or FSE

• Step 5 Evacuate the uterus.If using EVA or FSE
• Attach cannula to suction source.
• Evacuate remaining contents slowly.
• Check for signs of completion.
• To avoid losing vacuum, be careful not to
  withdraw the cannula opening beyond the cervical
  os. If vacuum is lost, re-establish it.
• Once evacuation is completed, detach vacuum
  source and remove all instruments.
• Withdraw cannula and place in decontamination
  solution.
• Step 6 Inspect the tissue removed from the
  uterus.

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The VA Procedure

• Absence of POC in a woman with symptoms of
  pregnancy may strongly indicate the possibility
  of ectopic pregnancy.

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Post-Procedure CareMVA, EVA or FSE

• Monitor recovery of the client
• Take vital signs before moving the client from
  the procedure area.
• Continue with pain management as needed.
• Encourage the woman to eat, drink and walk as she
  wishes.
• Explore the clients feelings and concerns and
  provide explanation and support as needed.

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Post-Procedure CareMVA, EVA or FSE (2)

• Check bleeding at least once before discharge and
  check to see that cramping has reduced. Prolonged
  cramping is not normal.
• Client may be discharged as soon as she is
  stable, can walk without assistance and has
  received post-procedure counseling and family
  planning information and services.
• In most instances, uncomplicated cases can be
  discharged in12 hours.

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Post-Procedure CareMVA, EVA or FSE (3)

• If FP services are available on-site, complete FP
  counseling and assist client in deciding on a
  method before she is discharged. Remember PAC is
  not complete without FP services.
• Provide other health services as needed (if
  available) such as tetanus prophylaxis or Rh
  immune globulin if client Rh-negative.
• Advise the client of signs that need immediate
  attention
• Prolonged cramping (more than a few days)
• Prolonged bleeding
• Bleeding more than a normal menstrual period
• Severe or increased pain
• Fever, chills
• Fainting

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VA Procedure Record Keeping

• Record information
• Record complete information on client chart and
  other forms as needed.

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Management of Problems during the VA Procedure

• The key to recognizing and managing problems
  during VA is to know that they can occur even
  under the best circumstances.
• Most problems are not serious and if recognized
  immediately and corrected or treated, the
  clients recovery will not be affected.

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Technical ProblemsVA Procedure

• Syringe is full (MVA)
• Keep a second prepared syringe on hand during the
  aspiration and switch syringes if one becomes
  full.
• Cannula is withdrawn prematurely (MVA, EVA, FSE)
• If the opening of the cannula is pulled into the
  vaginal canal with the valve still open, the
  vacuum will be lost.
• Cannula is clogged (MVA, EVA, FSE)
• Never try to unclog the cannula by pushing the
  plunger back into the barrel with the cannula tip
  still in the uterus.
• Syringe does not hold vacuum (MVA)
• Try lubricating the plunger and barrel with a
  drop of silicone. If this does not work, replace
  the O-ring. If the syringe still does not hold a
  vacuum, discard it and use another syringe.

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Procedural ProblemsMVA, EVA, FSE

• Less than expected tissue/No POC
• Consider possible ectopic pregnancy.
• Consider complete abortion or misdiagnosis.
• Incomplete evacuation
• Use correct size cannula.
• May need to repeat evacuation.
• Uterine perforation
• This is rare.
• Signs include severe pain, abdominal distention,
  cervical motion tenderness, shoulder pain and
  rigid abdomen.

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Other Problems

• Vaginal bleeding not due to pregnancy
• Break-through bleeding (hormonal contraceptive
  use)
• Uterine fibroids
• Ectopic pregnancy
• Delay in treatment of an ectopic is dangerous.
• Risk is higher in women with
• Previous ectopic pregnancy
• Pelvic infection
• IUD or progestin-only contraceptive use