10. Use a sterile cotton ball or gauze, saturated with iodine solution, held with sterile forceps. Antiseptic iodine solution is applied liberally to entire vagina, speculum surfaces, cervix, and cervical os. Do this three times, each time with a fresh sterile cotton swab, starting at the os and working out to outer vaginal lips and speculum.
11. Slowly and gently grasp cervix (in the 10 or 12 o’clock position) with sterile instrument, either ring forceps or tenaculum.
12. Dilate cervical os with smaller cannulas (4 - 5 mm), as necessary.
Use the ‘no touch technique’ for cannula insertion. Grasp the cannula at the base with sterile gloves and very carefully insert the cannula tip without touching anything else before contact with the cervical os.
13. A 6 mm cannula is usually adequate for pregnancies up to six or seven weeks LMP. The cannula should fit snuggly into the os. Rotate the cannula slightly at the inner os (sometimes known as the cervical canal) to help the cannula pass into the uterus. Note the measurement on the cannula as it passes through the inner os into the uterus.
14. The marks on the cannula indicate centimeters. Move the cannula slowly forward into the uterus until the back of the uterus (the fundus) is touched, but not more than 10 cm. A non-pregnant uterine cavity measures approximately 4 cm.
The cervix itself can have up to a 3 cm length, depending on the number of children a woman has had. A measurement of 8 cm or more (from the back of the uterus to cervical os) usually indicates pregnancy.
15. Establish vacuum. Blood and tissue will begin to flow into the tubing. One source suggests establishing a vacuum of at least 26 in. Hg. (660 mm), for all first trimester vacuum aspirations.[98] Another source[99] calculates the necessary cannula size and amount of vacuum based on the age of the pregnancy:
| Weeks LMP | Size of Cannula | In./Hg of Vacuum |
|---|---|---|
| 4 | 4 mm | 6.3 in. (160 mm) |
| 5 | 5 mm | 7.8 in. (200 mm) |
| 6 | 6 mm | 9.4 in. (240 mm) |
| 7 | 7 mm | 11 in. (280 mm) |
| 8 | 8 mm | 12.6 in.(320 mm) |
| 9 | 9 mm | 14.2 in. (360 mm) |
| 10 | 10 mm | 15.7 in. (400 mm) |
16. Gently push the cannula to the fundus. Rotate slightly while pulling back carefully (not past the noted inner os mark). Repeatedly stroke in and out, attempting to reach all parts of the inner uterus while carefully making one rotation of 360 degrees. Repeat if necessary, feeling for areas that feel smooth rather than rough.
17. Pause and empty the collection jar as necessary. Empty contents into a strainer and then a clear baking dish with a small amount of saline/water or vinegar/water solution added.
18. When the evacuation is complete, the person holding the cannula will feel a grating sensation on the uterine lining. The uterus may grip the cannula tightly. Red or pink foam (no tissue) may be seen in the cannula.
19. Release vacuum pressure before removing the cannula.
20. Place the cannula on the sterile tray until the procedure is determined complete.
21. To check for completion: a. Inspect Tissue i. Wash the aspired tissue and blood in a fine mesh metal strainer under running water to separate blood and clots.
ii. Transfer remaining tissue in the strainer into a clear glass dish containing ½ in. (1 cm) of water or saline solution.
Utilize a light behind the dish to help see the products of conception, which should include chorionic villi and fetal membrane, and after nine weeks LMP, fetal parts. The chorionic villi appear feathery and white, while the endometrium is smooth and transparent.
b. Perform a bimanual pelvic exam to check size and firmness of the uterus.
i. A smaller and firm uterus combined with observation of all expected products of conception in aspirated tissue indicates complete evacuation. (See Post-Abortion Care).
ii. Repeat procedure if uterus is still soft and has not reduced in size or if there is persistent brisk bleeding indicating an incomplete evacuation.
Cervix is not visible after speculum insertion.
• Inadequate lighting.
• Wrong size speculum.
• Cervix above or below speculum, try inserting point of speculum and pointing slightly to the left or right, then straightening out speculum once it is halfway inserted.
Uterus backs away when insertion of cannula is attempted.
• Use ring forceps or tenaculum to hold uterus while cannula is inserted.
Cannula will not pass through cervical inner os.
• Dilate the cervix with smaller sterile cannula.
• Use a light rotation at the inner os to ease passage.
• Use a sterile lubricant on cannula tip (New unopened small pack of KY Jelly).
No movement or little movement of blood through cannula and tubing.
• Possible vacuum leak – check connections.
• Clot clogging cannula tip. Try increasing vacuum a bit, if this does free clotted cannula tip, release vacuum, remove cannula and use a sterile object to clear the tip of cannula, then repeat procedure.
Cannula moves into uterus past the 10 cm mark.
• For most pregnancies prior to 7 weeks LMP, this would indicate uterine perforation Uterine perforation is very rare, but most likely to occur during dilation if metal instruments are used.
• Stop procedure, release vacuum, remove cannula from uterus, and seek more information. If uterine perforation is suspected, medical care should be sought immediately.
• More advanced pregnancy than expected. Careful pelvic examination will help determine gestational age.
No or only partial products of conception are seen.
• Not pregnant.
• Complete abortion already occurred – review medical history.
• Possible incomplete abortion, repeat procedure.
• Abnormal uterus (possible double uterus).
• Possible ectopic pregnancy. If ectopic pregnancy is suspected, medical care should be sought immediately.
• Possible molar pregnancy.
Many air bubbles in cannula and tubing, and vacuum decreasing.
• Possible vacuum leak, check connections.
• Pulling cannula too far out on pull stroke.
• Cannula too small for cervix; increase size of cannula.
Part III Alternative Self-Induced Abortion Methods
General Introduction
Alternative methods of self-induced abortion are documented in nearly every culture. Some alternative forms of abortion are ancient and some are more contemporary. Ancient methods of self-induced abortion include herbal, acupuncture, and massage. Contemporary alternative forms of abortion include homeopathic, yoga, and psychic. Alternative methods of self-induced abortion are generally believed to be more dangerous and less effective than modern methods of self-induced abortion based on clinical abortion procedures.
98
Benson, J. et al. “Meeting Women's Needs for Post-Abortion Family Planning: Framing the Questions
99
R.C. Bretherton, “Vacuum Aspiration of the Uterus.” (Letter),