1. Emergency Treatment Module 2 - Session 5 Vacuum Aspiration

2. Module 2 - Session 5 Objectives
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

3. 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.

4. 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.

5. 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.

6. 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.

7. MVA Instrument Labels

8. 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.

9. 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.

10. 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.

11. 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.

12. 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 valve—you 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.

13. 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.

14. 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.

15. 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.

16. 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.

17. The VA Procedure (2)
Step 2: Dilate the cervix (if needed; often the woman’s cervix is already dilated).
Step 3: Insert the cannula.
Step 4: Measure the size of the uterus.

18. The VA Procedure—If 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.*

19. The VA Procedure—If 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.*

20. The VA Procedure
*Absence of POC in a woman with symptoms of pregnancy may strongly indicate the possibility of ectopic pregnancy.

21. Post-Procedure Care—MVA, 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 client’s feelings and concerns and provide explanation and support as needed.

22. Post-Procedure Care—MVA, 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 in 1–2 hours.

23. Post-Procedure Care—MVA, 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

24. VA Procedure Record Keeping
Record information:
Record complete information on client chart and other forms as needed.

25. 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 client’s recovery will not be affected.

26. Technical Problems—VA 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.

27. Procedural Problems—MVA, 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.

28. 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