Care of Mother and Child At-Risk orwith

Problems (Acute and Chronic)-RLEModule #5

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Lesson Title: Manual Vacuum Aspiration and Dilatation Materials:

and Curettage SAS, OB book and pens
Learning Targets:
At the end of the module, students will be able to: References:
1. Discuss the impact of unsafe abortion on maternal
morbidity and mortality. Silbert-Flagg , JoAnne and Pilliteri, Adele
2. List the methods of medical and surgical post abortal (2018) Maternal and Child Health Nursing, 8th
care. Edition. USA: Lippincott Williams and Wilkins
3. Recognize post-abortal care as an essential
component of emergency obstetrical care and that it World Health Organization. (2015).
Pregnancy, childbirth, postpartum and
should be available in every health facility. newborn care: A guide for essential practice
(3rd ed.).

Perinatal Education Programme. (2020)

Maternal Care A Learning Programme for
Professionals

A. LESSON REVIEW/PREVIEW

B. MAIN LESSON
Post-Abortal Care
 Post-abortal care refers to the package of care needed to provide quality services following
spontaneous abortion and unsafe abortion.
 Post-abortal care services should include both medical and preventive care. Essential elements of the
PAC model include: Emergency treatment of incomplete abortion and potentially life-threatening
complications Post-abortal family planning counseling and services Links between post-abortal
emergency services and the reproductive health care system
 Family planning services are an essential component of PAC Services as an Essential Component of
Post-Abortal Care.
 Women who receive PAC without the necessary tools or information needed to prevent subsequent
unwanted pregnancies and abortions may find themselves returning to health centers for similar
services in the future.
 Lack of family planning information and tools leave women trapped in what has been called a harmful
cycle of unwanted pregnancy and unsafe abortion.

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 Research shows that reaching women at this critical stage helps to increase contraceptive use
significantly, leading to fewer repeat and possibly unsafe abortions.

Clinical Features for Diagnosis of Abortion

The following table provides a summary of the main signs and symptoms to aid prompt differential diagnosis of
an abortion.

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Management

General management
Every health care system must provide some level of PAC, whether at the district and/or community level. The
services provided will depend on the type of facility and its capacities.
Suggested post-abortal care services by level of health care facility and staff

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Management of Spontaneous Abortion

Threatened abortion Inevitable abortion
1. Medical treatment is usually not necessary. 1. If pregnancy is less than 16 weeks: Plan for
I MVA of uterine contents.
2. The woman is advised to avoid strenuous manual vaccum
activity and sexual intercourse, but bed rest is 2. If evacuation is not immediately possible:
not necessary. Give ergometrine 0.2% mg IM (repeated
after 15 minutes if necessary) OR
3. If bleeding stops: Follow-up in antenatal clinic. misoprostol 400 µg by mouth (repeated once
Reassess if bleeding recurs. after 4 hours if necessary).

4. If bleeding persists: Assess for fetal viability 3. Arrange for evacuation of uterus as soon a
(pregnancy test or ultrasound) or ectopic possible.
pregnancy (ultrasound).
4. If pregnancy is greater than 16 weeks:
5. Persistent bleeding, particularly in the
presence of a uterus larger than expected, Await spontaneous expulsion of product of
may indicate twins or molar pregnancy. conception and then evacuate the uterus to
remove any remaining product of
6. Do not give hormones because they will not conception.
prevent miscarriage
If necessary, infuse oxytocin 40 units in 1L
IV fluids (normal saline or Ringer’s lactate at
40 drops per minute) to help achieve
expulsion of product of conception.

5. Ensure follow-up of the woman after

treatment.
Incomplete abortion Complete abortion
1. If bleeding is slight to moderate and 1. Evacuation of the uterus is NOT necessary.
pregnancy is less than 16 weeks: Use fingers
or ring (or sponge) forceps to remove POC 2. Observe for heavy bleeding.
protruding through the cervix.
3. Ensure follow-up of the woman after the
2. If bleeding is heavy and pregnancy is less treatment.
than 16 weeks: Evacuate the uterus: MVA is
the preferred method of evacuation.

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Evacuation by sharp curettage should only be

done if MVA is not available.

3. If evacuation is not immediately possible: Give

ergometrine 0.2 mg IM (repeated after 15
minutes if necessary) or misoprostol 400 µg
orally (repeated once after 4 hours if
necessary).

4. If pregnancy is greater than 16 weeks: Infuse

oxytocin 40 units in 1 L IV fluids (normal saline
or Ringer’s lactate) at 40 drops per minute
until expulsion of POC occurs.

5. If necessary, give misoprostol 200 µg

vaginally every 4 hours until expulsion, but do
not administer more than 800 µg.

6. Evacuate any remaining POC from the uterus.

7. Ensure follow-up of the woman after the

treatment.
Management of Induced Abortion Performed in Unsafe Environment
Emergency treatment for post-abortal complications 5. Stabilization of emergency conditions and
includes: treatment of any complications—
1. An initial assessment to confirm the presence complications present before treatment and
of abortion complications. those occurring during or after the treatment
procedure.
2. Supporting the woman while assessing her
condition and explaining the treatment plan. 6. Assessment of the signs and symptoms of
septic abortion, such as:
3. Medical evaluation (brief history, limited fever >38.5°C 48 hours following abortion,
physical and pelvic examinations, history of chills or sweats,
excessive bleeding, easy bruising or known foul-smelling vaginal discharge,
blood disorder that could be due to lower abdominal tenderness and/or pain,
coagulopathy, and risk for excessive mucous from the cervix,
bleeding). prolonged bleeding (for more than 8hrs),
general discomfort,
4. Prompt referral and transfer if the woman flu-like symptoms,
requires treatment beyond the capacity of the hemodynamic and

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facility where she is seen. acid-based equilibrium changes.

7. As the condition worsens, the patient is less

alert with tachycardia, hypotension,
peripheries pale and clammy, nausea,
vomiting, and diarrhea. If a septic abortion
with hypotension out of proportion of the
blood loss, septic shock should be
suspected

8. Uterine evacuation to remove retained

product of conception.
Post-abortal Follow-up
Women who have had a spontaneous abortion: Women who have had an unsafe abortion:
 Must be supported psychologically.  Must be counselled on family planning
methods that can be started immediately
 Should be informed that spontaneous abortion (within 7 days).
is common and occurs in at least 15% (1 in
every 7) of clinically recognized pregnancies.  Family Planning Services as an Essential
Part of Post-Abortal Care.
 Must be reassured that their chances for a
subsequent successful pregnancy are good  Must be referred to any other reproductive
unless there has been sepsis or a cause of health services that may be needed:
abortion that has been identified as having an RhoGAM, tetanus prophylaxis or tetanus
adverse effect on future pregnancies (this is booster, treatment for sexually transmitted
rare). infections, cervical cancer screening, etc.

 Should be encouraged to delay the next  Must be invited to express their feelings and
pregnancy until they are completely fears related to the circumstances of the
recovered. unwanted pregnancy, such as rape, failed
contraception, lack of access to
contraception, etc.

Surgical and Medical Methods for the Management of Spontaneous and Unsafe Abortion, and
Approved by International Guidelines
 Medical methods, also known as non-surgical methods, make use of pharmacological drugs to treat
conditions of post abortion.

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 Surgical methods make use of transcervical procedures, such MVA, dilatation and curettage (D&C),
and dilatation and evacuation (D&E). Medical and surgical methods are safe, and can save the life of
the woman if used properly and effectively. In countries where abortion services are legal, they are
recognized as the safest approach to medical and surgical abortion care. The Society of Obstetricians
and Gynaecologists of Canada, the American College of Obstetricians and Gynecologists, the Royal
College of Obstetricians and Gynaecologists (UK), and WHO have all adopted guidelines for abortion
care.

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EMERGENCY INTERVENTIONS FOR BLEEDING IN PREGNANCY

INTERVENTION RATIONALE
1. Alert healthcare team of emergency Provides maximum coordination of care
situation.
2. Place woman flat in bed on her side. Maintains optimal placental and renal function
3. Begin intravenous fluid such as Ringer’s lactate Replaces intravascular fluid volume; intravenous line
with a 16- or 18-gauge Angiocath. is established if blood replacement will be needed
4. Administer oxygen as necessary at 6–10 L/min by Provides adequate fetal oxygenation despite lowered
face mask. maternal circulating blood volume
5. Monitor uterine contractions and fetal heart rate by Assesses whether labor is present and fetal status;
external monitor. external system avoids cervical trauma
6. Omit vaginal examination. Prevents tearing of placenta if placenta previa is
cause of bleeding
7. Withhold oral fluid. Anticipates need for emergency surgery
8. Order type and cross-match of 2 units of whole Allows for restoring circulating maternal blood
blood. volume if needed
9. Measure intake and output. Enables assessment of renal function (will decrease
to under 30 ml/hr with massive circulating volume
loss)
10. Assess vital signs (pulse, respirations, and blood Provides objective evidence of amount of bleeding;
pressure every 15 min; apply pulse oximeter and saturating a sanitary pad in less than 1 hr is heavy
automatic blood pressure cuff as necessary). blood loss; tissue may be abnormal trophoblast
tissue
11. Assist with placement of central venous pressure Provides more accurate data on maternal
or pulmonary artery catheter and blood hemodynamic state
determinations.
12. Measure maternal blood loss by weighing Provides objective evidence of amount of bleeding;
perineal pads; save any tissue passed. saturating a sanitary pad in less than 1 hr is heavy
blood loss; tissue may 1170 be abnormal trophoblast
tissue
13. Assist with ultrasound examination. Supplies information on placental and fetal well-
being
14. Maintain a positive attitude about fetal outcome. Supports mother–child bonding
15. Support woman’s self-esteem; provide emotional Assists problem solving, which is lessened by poor
support to woman and her support person. self-esteem.

Medical methods of treating spontaneous and unsafe abortion

Procedure for Manual Vacuum Aspiration.

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 Surgical methods of post abortion to evacuate the uterus

Surgical methods of post abortion include:

 MVA
 Dilatation and curettage
 Dilatation and evacuation

After any surgical method, immediate examination of POC is important to exclude the possibility of ectopic
pregnancy, verify any appearance suggestive of molar pregnancy, and to consider incomplete abortion.
1. Manual vacuum aspiration (MVA): Vacuum aspiration is the most preferred, appropriate, and cost-
effective procedure in low-resource settings. It is the preferred surgical technique up to 16 weeks. Its
high efficacy has been well established in several randomized controlled trials. Vacuum aspiration has
replaced D&C in routine use in most industrialized countries and in many other countries.

 With MVA, the vacuum is created using a hand-held, hand-activated, plastic 60 ml syringe. It takes from
3 to 10 minutes to complete, and can be performed on an outpatient basis, using analgesics and/or
local anesthesia.

 Though rare, complications with vacuum aspiration can include pelvic infection, excessive bleeding,
cervical injury, incomplete evacuation, uterine perforation, anesthesia complications, and ongoing
pregnancy.

 Abdominal cramping or pain and menstrual-like bleeding are normal side effects with any abortion
procedure. Precautions for performing manual vacuum aspiration

 In the course of the initial assessment, conditions may be discovered that indicate delaying the MVA
procedure and initiating other treatment(s) before beginning the MVA, or the need to use a different
technique for removing POC.

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Complications with Collaborative Management

2. Dilatation and curettage: Also known as sharp curettage, D&C involves dilating the cervix with
mechanical dilators or pharmacological agents and using sharp metal curettes to scrape the walls of
the uterus. It is less safe than vacuum aspiration and considerably more painful for women.

3. Dilatation and evacuation: D&E is used from about 12 completed weeks of pregnancy. It is the safest
and most effective surgical technique for later abortion where skilled, experienced providers are
available. D&E requires preparing the cervix with a prostaglandin, dilating the cervix, and evacuating
the uterus using electric vacuum aspiration with 14 mm to 16 mm diameter cannula and forceps.

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Check for Understanding

You will answer these questions below and it will be recorded as your quiz.

Essay (5 points each)

1. How should you decide whether a patient can be managed locally or whether she should be
transferred? Clinics and level 1 hospitals which do not have blood available must refer all patients
with an antepartum hemorrhage.

2. When you refer a patient, what precautions should you take to ensure the safety of the patient in
transit?

C. LESSON WRAP-UP
AL Strategy: Minute Paper
1. Please prepare a question or write a question in an index cards or half-sheets of paper to write
feedback to the following questions:
a. What was the most useful or the most meaningful thing you have learned this session?
b. What question(s) do you have as we end this session?

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 Care of Mother and Child At-Risk orwith
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Nam Class

Section: Dat

Lesson Title: Cerclage and Version Materials:

Learning Targets: SAS, OB book, pens
At the end of the module, students will be able to:
1. Assess a woman who is experiencing a complication References:
of pregnancy.
2. Formulate nursing diagnoses that address the needs Silbert-Flagg , JoAnne and Pilliteri, Adele
of a woman and her family experiencing a complication (2018) Maternal and Child Health Nursing, 8th
of pregnancy. Edition. USA: Lippincott Williams and Wilkins
3. Identify expected outcomes to minimize the risks to a
pregnant woman and her fetus when a sudden Cunningham, F. G., Leveno, K. J., Bloom, S.
L., Dashe, J. S., Hoffman, B. L., Casey, B. M.,
complication of pregnancy occurs as well as manage & Spong, C. Y. (2018). Williams Obstetrics
seamless transitions across differing healthcare (25th ed.). USA: McGraw-Hill Education.
settings.
Shirodkar Cerclage

Laparoscopic Cerclage

External Cephalic Version Video

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A. LESSON REVIEW/PREVIEW

B. MAIN LESSON
CERVICAL CERCLAGE
Cervical Cerclage- purse-string sutures are placed 3. Rescue Cerclage=is defined as cervical dilation
in the cervix by the vaginal route under regional of 1.5 cm or more by digital examination and
anesthesia, at approximately 12 to 14 weeks. membranes visible or prolapsed through the
This procedure is use as a surgical management for cervical canal. Replacement of the prolapse
cervical insufficiency. amniotic sac back into the uterus will usually aid
suturing or placing the patient in a Trendelenburg
Contraindications position, filling the bladder with 600 ml or placing
 Bleeding a Foley catheter to inflate a 30 ml balloon to
 Contractions deflect the amniotic sac while a cerclage suture
 Ruptured Membranes is tightened around the catheter tubing.

Types 4. Transabdominal Cervicoisthmic

1. McDonald procedure = nylon sutures are Cerclage=suture is placed art the uterine
placed encircling the cervix and pulled tight to isthmus that can be used and left until completion
reduce the cervical canal to 5-10 millimeters in of childbearing.(as seen below)
diameter. (as seen below)
=because of greater risks of bleeding and
complications during placement, this approach is
reserved for selected instances of severe cervical
anatomical defects or prior transvaginal cerclage
failure.

2. Shirodkar technique = sterile tape(5mm

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Mersilene Tape) is threaded in a purse-string  After the procedure, the woman should remain
manner under the submucous layer of the cervix on bed rest in a slight or modified
and sutured in place to achieve a closed cervix. Trendelenburg position for a few days to
(as seen below) decrease pressure on the new sutures.
 Usual activity and sexual relations can be
resumed in most instances after this rest
period.
 Although routinely accomplished by a vaginal
route, sutures may be placed by a
transabdominal route.
 Sutures are then removed at weeks 37 to 38 of
pregnancy so the fetus can be born vaginally.
 When a transabdominal approach is used, the
sutures may be left in place and a cesarean
birth is performed.

VERSIONS

 Fetal presentation is altered by physically substituting one pole of a longitudinal presentation for the
other, or converting an oblique or transverse lie into a longitudinal presentation.

1. EXTERNAL CEPHALIC VERSION (as seen on figure 6.30 A to D)

 Manipulations performed through the abdominal wall that yield a cephalic presentation.
 External cephalic version (ECV) reduces the rate of non-cephalic presentation at birth (Hofmeyr,
2015b).

INDICATIONS
 Breech presentation
 Transverse lie

CONTRAINDICATIONS
 early labor,
 oligohydramnios or rupture of membranes
 nuchal cord,
 structural uterine abnormalities
 fetal-growth restriction, and prior

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 abruption or its risks (Rosman, 2013).

 Prior Cesarean Section

COMPLICATIONS
 risks for placental abruption
 preterm labor
 fetal compromise
 uterine rupture
 feto-maternal hemorrhage
 alloimmunization
 amnionic fluid embolism
 death may also complicate attempts at external version
 dystocia
 malpresentation
 non-reassuring fetal heart patterns

2. INTERNAL PODALIC VERSION

 A fetus is turned to a breech presentation using the hand placed into the uterus (Fig. 45-26).
 The obstetrician grasps the fetal feet to then effect delivery by breech extraction.

INDICATION
 the only indication is when the fetus in transverse lie in case of second baby in twin gestation.

Technique for Internal Podalic Version

Prerequisites for Internal Podalic Version
Before undertaking the procedure of internal podalic version, the obstetrician must make sure that the

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following conditions are fulfilled:

• Cervix must be completely dilated.
• Liquor/amniotic fluid must be
adequate for intrauterine
manipulation.
• Fetal lie, presentation and FHR
must be assessed by an
experienced obstetrician before
undertaking the
procedure.

Actual Procedure
The procedure must be ideally
performed under general
anesthesia with the uterus
sufficiently relaxed.
• Under all aseptic precautions,
the clinician introduces one of
his/her hands into the uterine
cavity in a cone-shaped manner.
(b)
• The hand is passed along the
breech to ultimately grasp the fetal
foot, which is identified by
palpation of its heel.
While the foot is gradually brought down, clinician’s other hand present externally over the abdomen helps in
gradually pushing the cephalic pole upwards.(c)
• Rest of the delivery is completed by breech extraction.

Complications due to internal podalic version

Maternal Fetal
• Placental abruption
• Asphyxia
• Rupture uterus
• Cord prolapse
• Increased maternal mortality and morbidity
• Intracranial hemorrhage

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Check for Understanding

You will answer these questions below and it will be recorded as your quiz.

1. A 23-year-old G3P2 woman at 12 weeks’ gestation with a uterine anomaly presents asking if she should
undergo cerclage placement to prevent preterm birth. The decision to place a cerclage should be based on
which of the following?
a. The type of müllerian anomaly
b. Cervical length at 14 weeks’ gestation
c. The same criteria used for women without uterine anomalies
d. All of the above

2. Which of the following is an indication for transabdominal cerclage?

A. Twin gestation B. History of cervical insufficiency
C. History of failed transvaginal cerclage D. Prior preterm birth at 26 weeks’ gestation

3.A 38-year-old G1 undergoes a routine sonogram to survey fetal anatomy at 21 weeks’ gestation. The cervical
changes are found. She denies any complaints, including contractions. On sterile speculum exam she is noted
to be dilated 1–2 cm with bulging membranes just past the level of the external os. She undergoes 24 hours of
observation on labor and delivery without any change. What is the most likely diagnosis?
a. Inevitable abortion
b. Cervical insufficiency
c. Arrested preterm labor
d. Placenta Previa

4. A 38-year-old G1 undergoes a routine sonogram to survey fetal anatomy at 21 weeks’ gestation. The
cervical changes are found. She denies any complaints, including contractions. On sterile speculum exam she
is noted to be dilated 1–2 cm with bulging membranes just past the level of the external os. She undergoes 24
hours of observation on labor and delivery without any change. When counseling the patient regarding her
management options, you offer her expectant management versus intervention. Which intervention is most
appropriate?
a. Cerclage placement
b. Daily vaginal progesterone
c. 17-Hydroxyprogesterone acetate injections weekly
d. Expectant management with repeat cervical length in 1 week

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5. A 38-year-old G1 undergoes a routine sonogram to survey fetal anatomy at 21 weeks’ gestation. The
cervical changes as shown below are found. She denies any complaints, including contractions. On sterile
speculum exam she is noted to be dilated 1–2 cm with bulging membranes just past the level of the external
os. She undergoes 24 hours of observation on labor and delivery without any change. The patient elects to
proceed with cerclage placement. What is the most appropriate statement regarding her probable outcome?
a. There is a 20% risk of delivery prior to term.
b. There is a 33% risk of delivery prior to 35 weeks’ gestation.
c. There is a 50% risk of delivery prior to 36 weeks’ gestation.
d. There is at least a 50% risk of delivery prior to 28 weeks’ gestation.

6. In a woman without history of prior cesarean delivery, at what gestational age is removal of a prophylactic
transvaginal cerclage most reasonable?
a. 34 weeks’ gestation
b. 37 weeks’ gestation
c. 39 weeks’ gestation
d. Defer until the onset of labor

7. Which of the following is an indication for transabdominal cerclage?

a. Twin gestation
b. History of cervical insufficiency
c. History of failed transvaginal cerclage
d. Prior preterm birth at 26 weeks’ gestation

8. When counseling a patient regarding prophylactic cerclage placement, which of the following is a
known risk? SELECT ALL THAT APPLY
a. Bleeding
b. Infection
c. Membrane rupture
d. Cervical Insufficiency

9. Manipulations performed through the abdominal wall that yield a cephalic presentation.
A. External Cephalic Version
B. Internal Podalic Version
C. External Podalic Version
D. Internal Cephalic Version

10. A fetus is turned to a breech presentation using the hand placed into the uterus.
A. External Cephalic Version
B. Internal Podalic Version

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C. External Podalic Version

D. Internal Cephalic Version

C. LESSON WRAP-UP
AL Strategy: Minute Paper
1. Please prepare a question or write a question in an index cards or half-sheets of paper to write
feedback to the following questions:
a. What was the most useful or the most meaningful thing you have learned this session?
b. What question(s) do you have as we end this session?

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