CHAPTER
8 - EQUIPMENT AND INSTRUMENTS
Basic equipment for aspiration include:
1. An operating table with leg supports. A simple table is
adequate. The possibility to change the height is preferred but not
strictly necessary.
2. An autoclave to sterilize the instruments is preferred over
other types of steriliser.
3. A powerful suction pump, preferably one specially designed for
termination of pregnancy.
4. An ultrasound scanner prevents most of the complications which
may arise. An abdominal transducer is used for advanced pregnancies,
a vaginal transducer makes precise diagnosis of early pregnancy and
such conditions as ectopic pregnancy possible.
5. Beds are preferred over chairs or reclining seats for recovery
after the procedure.
To enable a smooth and rapid patient flow the instruments should
be packed in standard packs. Each pack contains all instruments
necessary for the aspiration, wrapped up in sterilizing paper and
sterilized in an autoclave. Some disposable items which can stand
autoclaving may be added to the pack: gauze, a hygienic pad and a
window towel. Instruments which are used relatively seldom may be
packed in a smaller number of additional packs. Such a pack can be
opened if the need arises. A checklist of the contents of these
standard packs is given in Appendix 7.
A rigid routine must be maintained in the instrument handling
room. The used instruments are washed and thoroughly checked for
cleanliness. Then the instruments for one of the standard packs are
laid together with the business ends pointing in the same direction
to facilitate the no-touch technique. The instruments are wrapped in
sterilizing paper. Gauze, hygienic pad and a (easily self made)
window towel are added. The pack is closed with autoclaving tape and
the date and the initials of the packer written on the pack. Four
packs fit in a small autoclave. During packing the checklist should
be consulted. This reduces the occurrence of a missing instrument
during a procedure.
Work in the instrument room is greatly reduced if the doctor
adopts the neat habit to consequently lay the used instruments apart
from the clean ones. This appears to be difficult. Some doctors seem
to have pleasure in making a bloody mass of the sterile field if not
the whole theater. I always use the sterile paper in which the gloves
are packed as a sterile field for the used instruments. The
instruments which have not been used can be packed without cleaning.
Instruments for the preparation of the patient, vaginal toilet
and shaving, need not be sterilized. Cleaning and disinfection is
enough. A common speculum and two swab forcepses is enough. Further
some gauze, a disposable shaver and a kidney dish and a bottle with a
1% cetrimide solution. The vaginal toilet is described in
Chapter
9.
For termination of a pregnancy a single blade speculum
(Kristeller) and a tenaculum forceps are used to gain access to the
uterus. The single blade speculum gives much more freedom for the
instruments.A disadvantage is that it may drop out of the vagina and
that an assistant is necessary to hold the tenaculum forceps. One of
the most practical specula is the Collin or the slightly more
complicated Trélat.
Dilation is done with a number of dilators. The tapering type
(recommended is the Hawkin Ambler dilator) is preferred over the
Hegar type.
Dilation with a tapering dilator is much less traumatising. But
if the pregnancy is very young there is a danger of perforating the
fundus if the dilator is brought in too deep.
After dilation the uterus is evacuated with a disposable plastic
suction curette. These plastic curettes can not be autoclaved, but
they may be sterilised a number of times in Cidex®. A slender
forceps is necessary to remove tissue which is fixed in the canula or
trapped in the cervical canal.
The Karman canula is made from hard nylon. We use this type to
perform a gentle curettage after evacuation of the uterus to remove
small placental rests. This diminishes the incidence of bleeding
after a termination. A small blunt curette may be added for those who
want to do a check curettage. However, too rigorous curetting may
damage the basal layer of the mucosa which may lead to placenta
accreta or Asherman's syndrome in later pregnancies.
For advanced pregnancies a few extra instruments can be packed.
Some bigger Hawkin Ambler dilators, a bigger curette and one or two
ovum forceps. Since they are seldom needed a few packs suffice. A few
instruments which are very seldom needed may be packed individually.
They consist of a narrow speculum if access to the vagina is
difficult and a few very thin dilators for the infantile or rigid
cervix and for those cases in which the ostium externum is
unaccessable for bigger dilators.