These procedures have become the standard for termination of pregnancy from 6 till 23 weeks. They form the most rapid procedure with the lowest incidence of complications. Under 5 weeks the risk of failure or retention is relatively high, especially if a very tiny soft canula is used. Without thorough experience the second trimester pregnancies should not be attacked. The beginner should stick to 8 till 10 week pregnancies and gradually build up his experience. The best way to secure a good clinic routine and to avoid complications is to follow a rigid procedure in all cases. Appendix 5 and Appendix 6 provide a checklist of such a clinic routine.

In almost every stage of the procedure difficulties may be encountered and complications can arise. These are discussed in Chapter 11 and Chapter 12 respectively. In rare cases the procedure may fail altogether so that the pregnancy develops normally. This topic is discussed in detail in Chapter 13.

Conditions for aspiration are the existence of an intra uterine pregnancy and the administration of a suitable premedication and anaesthesia. A thorough examination, both physically and with ultrasound scan, should ascertain the diagnosis and rule out such complications as too far advanced pregnancy, ectopic pregnancy, and congenital or secondary deformations. Sterility should be maintained, not only by using sterile gloves but especially by using the no-touch technique. The business end of the instruments should never be touched. This rules out the use of double sided dilators which seem to be popular with gynaecologists. It is possible to do a termination even of a far advanced pregnancy while keeping one's hands clean. Also, the used instruments should be kept apart from the clean ones. The sterile paper in which the gloves are packed can be used to place the used instruments on. Since in many cases only a few instruments are used this diminishes greatly the work load in the instrument room.

The total procedure can be summarised as follows:



3.Vaginal Toilet and Local Anaesthetic.

4.Prepare to start the procedure.

5.General Anaesthesia if applicable.

6.Introduce a Speculum and fix the Cervix.

7. Dilation of the cervix

8. Aspiration

9.Forcipal Removal of Fetal Parts (Advanced Pregnancy).

10.Blunt Curettage (optional).

11.Check the products.

12.Check for Empty Uterus.

13.Finish the Procedure.

1. EXAMINATION - This is discussed in Chapter 3. Difficulties in case of vulvar of vaginal inflammations, vulvar or vaginal surgery, persistent hymen, vaginism are discussed in Chapter 11. Complications in this stage in the case of burst ectopic pregnancy or burst ovarian cyst: Chapter 12

2. PREMEDICATION - The premedication and its possible side effects are described in Chapter 5. An obvious difficulty arises if no suitable vein can be found. A real complication is rare. One case is described in Chapter 5 were an aberrant artery was entered.

3. VAGINAL TOILET AND LOCAL ANAESTHESIA - The necessity of a vaginal toilet is a matter of dispute. Some find it necessary to sterilise the vagina and cervix as far as that is possible to prevent infecting the uterus. Others consider this impossible and argue that it only disturbs the natural flora of the vagina. It is something like wiping the skin with a bit of spirit before an injection. If you don't do it the chance to get an infection is practically nil. But in case of a rich fluor most doctors will feel more comfortable if they clean the vagina.

If a vaginal or cervical infection is suspected ideally this is treated before the termination is undertaken. Since that is impractical, some antibiotic protection may be considered. A broad spectre antibiotic, like doxycycline or ampicillin, may be given. Administration of 500 mg doxycycline by mouth from which 200 directly after the procedure and continuing the course with 100 mg per day during three days seems to avoid most infections. A reliable single dose antibiotic which covers most infections, even resistant gonococci, is ceftriaxone 250 mg IV. In the early days of abortion clinics antibiotics were given or prescribed as a routine. It was soon understood that very few infections are seen after a proper aspiration or D&E under sterile conditions. Furthermore in healthy women the uterus has enough resources to defend itself against infections provided if it is completely emptied. Retained tissues form a perfect medium where bacteria can grow and where they are not reached by antibiotics.

Recommended is the following protocol for vaginal toilet:

1. Insert a Collin or similar speculum.

2. Remove vaginal fluor with a dry swab.

3. Spray a watery solution of a disinfectant like chlorhexidine or cetrimide into the vagina and swab.

4. At this stage, inject the local anaesthetic.

5. Spray again, bring in another forceps with swab. Take the speculum out while leaving the forceps with the swab inside and swab the vagina again. This ensures cleaning of the vaginal walls that have been covered by the speculum.

6. Shave only the hairs around the vulva which may touch the instruments.

7. In case of suspected vaginal infection give 200mg of doxycycline by mouth, and 100mg before the patient leaves the clinic. Give two tablets of100mg to take the following days. Or inject ceftriaxone 250 mg IV.

The same difficulties as described during the examination are applicable. They are described in Chapter 11. To avoid bleeding in advanced pregnancies a local anaesthetic containing noradrenaline should be given, even in case of general anaesthesia. Local anaesthesia and its complications are described in Chapter 5. An injection of diazepam should be kept ready for the occasional occurrence of epileptiform fits of muscular contractions.

4. PREPARE TO START THE PROCEDURE - A few minutes should be waited to allow the local anaesthetic to take full effect. During this time the pack of instruments is opened, sterile gloves are put on and the sterile paper in which they were packed is laid on the instrument table for the used instruments. The lower abdomen and buttocks are now covered with a sterile towel with a window to admit access to the vagina. A window towel can be purchased as a separately packed sterile piece of paper with a hole in the middle. It is simple, and much cheaper, to make such towels. A piece of sterilising paper, about 50 x 50 cm, is folded in four and one corner cut off, resulting in a nice diamond shaped window.

5. GENERAL ANAESTHESIA - The chosen general anaesthetic can now be injected. To avoid bleeding the combination of local anaesthetic containing noradrenaline and general anaesthesia is recommended in advanced pregnancies. Combining local and general anaesthetic has the effect that pain is greatly reduced so that no analgesics are necessary. General anaesthesia is discussed in Chapter 5. .

6. INTRODUCE A SPECULUM AND FIX THE CERVIX - When working alone the Collin speculum seems first choice. A single bladed speculum, preferably a Kristeller, is also recommended. This gives much more freedom of movement which facilitates the procedure. A disadvantage is that an assistant is required to hold the tenaculum forceps, while the doctor holds the speculum with one hand and does the operation with the other. For second trimester operations this seems almost impossible. A weighted Auvard speculum is less suitable in case of local anaesthesia. The weight and the crude form of the blade are unpleasant for the patient.

If a double bladed speculum is preferred a type which allows much freedom is recommended, like the Trélat or Collin. Difficulties in entering the vagina are described in Chapter 11.

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