Intra-uterine procedures

General precautions (asepsis, antibiotic therapy, anesthesia, preventing trauma)

OBLIGATORY ASEPSTS (clean with chlorhexidine (+ cetrimide) (see table page 7), drapes, gloves, and sterile compresses etc.), ALL INTRAUTERTNE PROCEDURES MUST BE FOLLOWED BY ANTIBIOTIC THERAPY, (PPF 4 million units for example IM for at least 5 days or ampieillin), HEMOSTASIS (ergometrine 0,1 mg IM x 1).

ALL INTRA-UTERINE PROCEDURES MUST BE CONDUCTED UNDER THE AUSPICES OF AN ANESTHETIST, the most rapid general anesthetic is ketamine IM (5 mg/kg).

ALL INTRA-UTERINE PROCEDURES MUST BE AS ATRAUMATIC AS POSSIBLE, for in all parts of the third world, sterility is seen not only as an individual problem but also a family and social problem.

All intra-uterine procedures, and in particular curettage, need practical training. The technique cannot be learn from a manual.

All intra-uterine procedures risk hemorrhage: always ensure a good venous line.

Artificial removal of the placenta

Manual removal of the placenta.

Indication

When more than 45 minutes elapses between a normal delivery and the delivery of the placenta.

Technique
(Figure 106)

· Intravenous line.

· Patient in lithotomy position, general anesthetic, clean the vagina with antiseptic, and wear sterile gloves.

· The left hand of the surgeon grasps the fundus of the uterus.

· The right hand pronated is advanced to the fundus and the fingers find the line of cleavage between the placenta and the uterine wall, that is to say the hand is advanced until the forearm is within the genital canal.

· Once the line of cleavage has been found, use the edge of the pronated hand as a knife, to dislodge the placenta.

· Next, explore with the fingers to ensure that the uterine cavity is empty and remove the placenta before the uterus contract.

· Give systemic antibiotics for at least 5 days.

· 1 injection of ergometrlne 0,1 mg IM.

FIGURE

Uterine exploration

Exploration of the uterus with a finger.

Indications

· Any suspicion of a retained placenta (always examine a placenta).

· Hemorrhage following delivery: all hemorrhages occuring within 24 hours of delivery.

Attention: if the placenta is complete and the uterus is contracted, only examine under a general anesthetic.

Technique

· Intravenous catheter

· The same procedure and aseptic technique as for artificial removal of the placenta.

· Systematically explore the uterus: the two faces, the two sides, the fundus and the two corners with the finger searching for and removing placental tissue.

· Systemic antibiotic therapy for at least 5 days.

FIGURE

· Ergometrine 0,1 mg IM digital curettage

Digital extraction of placental fragments after a miscarriage.

Indications

· Hemorrhage or retention of products of conception.

· Dilate the cervix with one, or two fingers if possible.

Technique
(Figure 107)

· Same preparation and asepsis as for uterine exploration.

· Introduce the index and middle fingers into the uterine cavity if possible.

· Examine systematically and remove residual fragments.

· Antibiotic therapy for at least 5 days.

Curettage

Removal of the remaining products of conception following a miscarriage.

Indications

When dilatation of the cervical neck is insufficient using curette technique: always prefer digital curettage when possible.

ATTENTION: curettage of a febrile patient: treat with antibiotics and wait for a fall in fever before curetting. The decision must be weighed against the risk of hemorrhage.

Material

· Speculum or vagina valve, Muzeux forceps (or Pozzi to hold the cervix, bougies for dilating the neck).

· Blunt curette, without hole, not too small: if too small, there is a risk of trauma. With a large curette, it is less dangerous, the diameter should be approximately the size of a tea-spoon and the limit is the degree of dilatation of the neck obtained with the bougies.

Technique
(Figure 108)

· Place the patient in lithotomy, position the sterile drapes, clean the perineum and vagina with polyvidone iodine (see table page 7), give general anesthesia.

· Introduce a speculum or vagina valve, holding the cervix with certical forceps (Museux forceps).

· Introduce the first dilator into the cervical canal, gently in the axis of the uterus ; there is a sudden loss of resistance when the internal os is reached. This first dilator is pushed as far as the fundus in order to estimate the size. With the following dilators, introduce by increasing sizes, until the cervix is dilated sufficiently to introduce the curette. ATTENTION: do not force: there is a risk of uterine perforation !

· The curette is then introduces as far as the fundus and explored, with the products drawn towards the cervical neck.

· The curette should be held between the thumb and index finger, with the other fingers on the shaft, allowing forward and backward movement: do not place the curette in the palm of the hand.

· Remove the fragments and do not damage the mucosa. Do not wait for the grating sensation, which means that the curette is too deep.

· Systematically explore the sides, walls, fundus and corners and check with the finger that the uterus is empty.

· Systemic antibiotics for at least 5 days.

FIGURE

Complications (Figures 109, 110)

· Persistent hemorrhage: Incomplete curettage, followed by uterine inertia; administer 0,2 mg of ergometrine IM and repeat as needed up to 4 hours. Do not administer more than 1,5 mg.

· Cervical damage by dilatation: Usually partial, lateral or submucosal. Heals by itself.

· Perforation: When this is diagnosed (forced instrumentation producing severe pain), lying the patient down and administering antibiotics (ampicillin: 4 g/day in 4 divided doses for at least 7 days) is usually sufficient. Sometimes, signs of peritonitis appear in the following days (pain, contracture) and surgery is needed.

· Infections: Endometritis, salpingitis, pelviperitonitis, septicemia must be prevented by rigorous asepsis, atraumatic procedures and systemic antibiotic therapy.

· Sterility: Obstruction of the ovarian tubes, infection, incompetent cervix. Uterine adhesions, obstetrical complications (placenta previa, adhesions), ectopic pregnancies.

FIGURE

FIGURE