ANNEX 11 - MANUAL VACUUM ASPIRATION (MVA)

Preparing Cannulae and Vacuum Syringes

Instruments need to be sterile when they are inserted through the cervix. The parts of dilators, cannulae, or uterine sounds that will enter the uterus should not touch objects or surfaces that are not sterile, including the vaginal walls, before being inserted.

1) Have ready several cannulae of approximately the size you will need, based on the indication for use and the uterine size. Each cannula is sterilized in the wrapper; check to make sure the wrapper is intact.

For Treatment of Incomplete Abortion, the largest size cannula which can be readily admitted by the cervix, and is adequate for evacuation, should be used. It is important to use a cannula that fits snugly through the cervix in order to transfer the vacuum without leaks from the syringe to the uterus. It is advisable to have cannulae of several sizes on hand. The cannula sizes listed here are guidelines; the actual size needed may vary.

Approximate Uterine Size (weeks LMP)	Approximate Cannula Size
5-7 LMP	5 mm
7-9 LMP	6 mm
9-12 LMP	7-12 mm

2) Select syringes, cannulae, and adapters (if needed), referring to the following chart. It may be helpful to prepare two syringes before beginning a procedure because the quantity of aspirate is difficult to predict. Note that the coloured dots on the cannulae match the colour of the appropriate adapter.

Cannula Size	Adapter Colour	Syringe Type
4, 5, 6 mm	No adapter needed	Single
4, 5, 6 mm	Blue	Double
7 mm	Tan	Double
8 mm	Ivory	Double
9 mm	Dark brown	Double
10 mm	Dark green	Double
12 mm	No adapter needed	Double

3) Inspect the syringes. A syringe must be able to hold a vacuum in order to be effective. Discard syringes with any visible cracks or defects, or ones that do not hold a vacuum.

4) Attach the adapter (if required) to the end of the syringe or cannula. The cannula will be attached to the syringe via the adapter later, after the tip of the cannula has been inserted through the cervix.

5) Check the plunger and valve(s). The plunger should be positioned all the way into the barrel and the pinch valve(s) should be open, with the valve button(s) out.

6) Close the pinch valve(s) by pushing the button(s) down and forward toward the syringe tip. You will hear and feel the valve(s) lock into place.

7) Prepare the syringe by grasping the barrel and pulling back on the plunger until the arms of the plunger snap outward at the end of the syringe barrel, holding the plunger in place. Check the stable positioning of the plunger arms. Both plunger arms must be fully extended to the sides and secured over the edge of the barrel. With the arms snapped in this position, the plunger will not move forward and the vacuum is maintained.

Incorrect positioning of the arms could allow them to slip back inside the barrel, possibly injecting the contents of the syringe or air into the uterus. Never grasp the syringe by the plunger arms.

8) Check the syringe for vacuum tightness before use. Leave the syringe for several minutes with the vacuum established. Open the pinch valve(s) by releasing the button(s). You should hear a rush of air into the syringe, indicating that there was a vacuum in the syringe. If you do not hear a rush of air, lubricate the o-ring with silicone and test the vacuum again. Replace the o-ring or use another syringe if the syringe still will not hold a vacuum.

9) Repeat steps 5 through 8 to reestablish the vacuum at the time of the procedure.

The Manual Vacuum Aspiration Procedure

Observe a No-Touch Technique throughout the procedure: any instruments, or parts of instruments, that enter the uterus need to be sterile. Do not contaminate the cannula. Be careful not to allow the tip to touch objects or surfaces before being introduced through the cervical canal.

1) Assess the woman's need for pain control medication and administer as needed. Generally, paracervical block, analgesia, and/or mild sedation are sufficient for the patient's comfort during the procedure. Precautions to paracervical block include screening for allergy to the local anaesthetic, and taking care not to inject into a blood vessel. It is preferable that the patient be awake during the procedure to alert the clinician to any sudden increase in pain (indicating possible perforation) and to avoid a long recovery time; heavy sedation or general anaesthesia is rarely necessary and carries additional risk.

2) Assess the size and position of the uterus by means of bimanual exam. Be alert for any signs of infection, and treat promptly according to standard protocols.

3) Insert the speculum to expose the cervix.

4) Inspect the cervix for dilation and signs of infection, trauma, or laceration.

5) Swab the cervical and vaginal areas with an antiseptic solution. The perineum should be cleansed but extensive preparation of the perineal area is not necessary.

6) Hold the cervix steady with a tenaculum and gently apply traction to straighten the cervical canal.

Administer paracervical block, if needed. The cannula can be used for sounding by counting the dots visible on the cannula when it is inserted to the fundus. The dot nearest the tip of the cannula is 6 cm from the tip, and the other dots are at 1 cm intervals.

7) Dilate the cervix (as required). Cervical dilation is necessary when the cervical opening's size will not allow passage of a cannula appropriate to the uterine size. Cervical dilation is not usually required for endometrial biopsy. When required, dilation should be done gently with mechanical or osmotic dilators or with cannulae of increasing size, taking care not to traumatize the cervix.

8) Introduce the cannula gently through the cervix into the uterine cavity just past the internal os. Rotating the cannula with gentle pressure often helps ease insertion.

9) Attach the prepared syringe to the cannula, holding the end of the cannula in one hand and the syringe in the other. Make sure that the cannula does not move forward into the uterus as you attach the syringe.

10) Push the cannula slowly into the uterine cavity until it touches the fundus. Then withdraw the cannula slightly.

11) Release the pinch valve(s) on the syringe to transfer the vacuum through the cannula to the uterus. Bloody tissue and bubbles should begin to flow through the cannula into the syringe.

12) Evacuate the contents of the uterus by moving the cannula gently and slowly back and forth within the uterine cavity, rotating the syringe as you do so.

It is important not to withdraw the cannula apertures beyond the cervical os, as this will cause the vacuum to be lost.

While the vacuum is established and the cannula is in the uterus, never grasp the syringe by the plunger arms to ensure that the plunger arms do not move from their locked position on the rim of the barrel. Accidentally allowing the plunger to slip back into the syringe may eject tissue or air back into the uterus.

13) Check for signs of completion. The procedure may be much quicker than dilation and curettage and is complete when the following conditions occur:

Red or pink foam and no more tissue is seen in the cannula, a gritty sensation is felt as the cannula passes over the surface of the evacuated uterus, and the uterus contracts around (grips) the cannula.

14) Detach syringe and remove all instruments (cannula, tenaculum, and speculum).

15) Inspect aspirated tissue.

Inspect the aspirated tissue for quantity and for presence of products of conception to judge its correspondence to the duration of gestation and to assure complete evacuation of an intrauterine pregnancy. Products of conception include villi, fetal membranes, or, after 9 weeks LMP, fetal parts. Absence of villi may signal an ectopic pregnancy. Strain and rinse the tissue to remove excess blood and clots and then place it in a clear container of water or weak acetic acid (vinegar) to examine visually. Samples of tissue may also be sent to the pathology lab as indicated. Follow standard infection control protocols for handling samples.

16) Monitor patient's recovery.

a) Take vital signs while the patient is still on the treatment table.

b) Allow the patient to rest comfortably where her recovery can be monitored.

c) Check bleeding at least once before discharge. Check to see that cramping has subsided. Prolonged cramping is not considered normal.

d) If the woman is Rh negative, administer Rh immune globulin before discharge.

The patient may be discharged as soon as she is stable and ambulatory.

17) Provide post-operative counselling and information to patient, including:

· Signs of a normal recovery:

- some uterine cramping over the next few days which may be eased by mild analgesics
- a normal menstrual period should begin within 4-8 weeks

· Instructions for taking any prescribed medications

· Information about personal hygiene and resumption of sexual activity, resumption of menses, and family planning:

- patient should not have intercourse or put anything into the vagina until a few days after bleeding stops (no sex, no douching, no tampons)

- patient's fertility will return soon after the procedure, so she needs contraceptive counselling and referral if another pregnancy is not desired at this time

· Schedule follow-up visit as required

· Signs and symptoms requiring immediate emergency attention:

- prolonged bleeding (more than two weeks)
- bleeding more than normal menstrual bleeding
- severe or increased pain
- fever, chills, or malaise
- syncopy (fainting)

· Sources of emergency care (if it is needed)