3. Cut or torn cervix. (1 out of 100 clinical MVAs) Often a tenaculum is used to hold the cervix in a clinical setting. The tenaculum is sharp and can cut the cervix. Using a ring or sponge forceps makes cervical laceration less likely. Rarely stitches are needed to repair a torn cervix.
4. Pelvic infection. Introduction of bacteria into the uterus is the cause of pelvic infection. Infection is a complication that occurs in 5% of clinical abortions. To help prevent infection, follow the no touch technique, monitor for high temperature and low blood pressure, and avoid introducing anything into the vagina for three weeks after the procedure (see Post-Abortion Care). If signs of infection present, seek immediate medical attention and antibiotics. Antibiotics usually clear up the infection. In rare cases, a repeat procedure, hospitalization or surgery is required.
5. Hemorrhage. Hemorrhaging is defined as filling three or more thick pads in three hours or less. This requires immediate emergency medical care. Rarely, an MVA, medication, surgery, or blood transfusion may be required.
6. Hematometra. Uterus becomes distended with blood and clots. When a bimanual exam (see Appendix C) is done the uterus often feels larger than before the procedure and extremely tender. Hematometra requires that the uterus be re-aspirated. Regular uterine massage after the menstrual extraction procedure can help prevent hematometra.
7. Unrecognized ectopic pregnancy. An ultrasound can diagnose an ectopic pregnancy. After a menstrual extraction, the absence of villi or gestational sac in the expelled contents may indicate a possible ectopic pregnancy. Most ectopic pregnancies present serious symptoms of extreme appendicitis-like pain before 9 weeks LMP.
8. Death. (1 out of 100,000 clinical abortions) Death rarely occurs in abortion; however the risks of self-induced abortion are significantly greater than an abortion in a clinical setting. Childbirth is more risky than clinical abortion up to 20 weeks LMP.
Menstrual extraction requires careful practice and memorization of the steps of the procedure. Practice of menstrual extraction can be simulated through the use of a ripe papaya to simulate a uterus.[96] The papaya is held still by a partner, and all the steps of menstrual extraction are practiced. A roll of paper may be taped to the papaya to simulate the vagina, and ‘no touch technique’ can be practiced.
The ‘no touch technique’ is a technique of menstrual extraction which reduces the risk of infection from cross contamination of the cannula or dilators. With the ‘no touch technique’ any sterile items that will enter the unsterile vaginal cavity (dilators or cannulas) are not allowed to touch anything except the cervical os. Slowly and carefully with a steady hand the dilators and cannulas are introduced into the vagina (held open with a speculum) without touching anything but the cervical os.
Once comfortable with the procedure with a papaya, practice can be expanded to include women who wish to have their menstruations removed. Only then, after repeated practice, should any group attempt menstrual extraction for the purpose of abortion.
Careful sterilization of all equipment (see Appendix F), washing of hands, wearing sterile gloves, and practice of no touch technique will help prevent infection of the uterus during the menstrual extraction procedure.
Necessary Items for Menstrual Extraction:
1. Del-EM™, MVA syringe, or Mityvac™ hand vacuum pump kit with gauge:
The Del-EM™, invented by Lorraine Rothman in 1971, is a simple construction made from widely available materials:
a – Check valve
b – Syringe
c – Collection jar
d – Karman cannula
The MVA Syringe is a single use disposable locking plastic syringe attached to a plastic Karman Cannula. MVA syringes are widely used in clinical settings to perform first trimester abortions.
e – Plastic MVA syringe
f – Karman cannula (magnified)
The Mityvac™ hand vacuum pump with gauge, also called a brake bleeder, is available online and at some automotive part stores (see Resources).
g - Mityvac™ hand vacuum pump with gauge.
h – Collection Jar
i – Karman cannula
2. Karman cannula set with sizes ranging from 3 – 14 mm.
3. Ring or sponge forceps.
4. Sterile gloves.
5. A few sterile towels and a cookie sheet or tray.
6. Iodine disinfectant solution and sterile cotton balls.
7. A sterile speculum.
8. Paracetamol, acetaminophen (optional).
9. Antibiotics, preventative regime (see Appendix I).
10. Large pot of boiling water or a pressure cooker to sterilize cannulas and forceps. (See Appendix F).
11. Hydrogen peroxide.
12. Light source: Flashlight, headlamp, or swing arm drafting light.
Note: The Mityvac™ hand vacuum pump, although primarily used to bleed brakes on automobiles, is also sold for a variety of hobby applications. The gauge can be used to establish a specific amount of vacuum; this increases effectiveness and can help indicate if there is a clot blocking the cannula tip or a leak in a connection. An air embolism due to user error of the Del-EM™ is less likely with the Mityvac™, as these hand vacuum pumps are self contained.[97]
1. The group participating in the procedure should be fully familiarized with the equipment and the procedure.
2. Dilate the cervix using pharmaceuticals; if necessary (see Appendix E).
3. Sterilize the cannulas, a tray, several towels, speculum, cotton balls, gloves, and forceps. Also, sterilize some items that can be used to clear a clot in the cannula, such as, a few opened paper clips. All other equipment need not be sterile, as it willnot be entering the uterus, however all equipment should be clean. (see Appendix F).
4. Remove tray sterilized from oven; using sterile gloves or forceps place sterile towel on tray. Using sterile forceps, place sterilized cannulas on toweled tray. Place sterile towel over tray holding sterile equipment. Place tray of sterile tools in a safe place near procedure area. Do not allow the tray to be disturbed or to sit for longer than two hours before use.
5. Thirty minutes prior to the procedure, an optional pain relieving medication and/or infection preventative antibiotic can be taken (see Appendix I).
6. Perform bi-manual pelvic exam to assess size and position of uterus; clean single use gloves may be worn to protect the assistant and patient from disease transfer, however gloves need not be sterile (see Appendix C).
7. Wash hands welclass="underline" a. Remove all jewelry.
b. Scrub all surfaces from fingertip to elbow for 30 seconds with antibacterial soap.
c. Rinse from fingertip to elbows.
d. Air dry or dry with a sterile towel, again fingertip to elbow.
e. Do not allow hands to come in contact with objects that are not disinfected or sterile.
f. If hands touch a contaminated surface, repeat washing of hands.
8. Carefully put on sterile gloves.
9. Speculum can be inserted. Ideally, the woman having the procedure should have the knowledge and ability to insert her own speculum (see Appendix D).
96
Marreen Paul and Kristin Nobel, “Papaya: A Simulation Model for Training in Uterine Aspiration,”
97
There was one known miss-construction of the Del-EM™, where the check valve was put on the wrong way. Instead of establishing a vacuum, air was accidentally pushed into the uterine cavity causing an air embolism; the woman recovered completely.