Second-Trimester Dilatation and Evacuation (D

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Second-Trimester Dilatation and Evacuation
(DE) abortion
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Objectives

• Describe taking a medical history specific to
  second-trimester abortion
• Evaluate three ways of pregnancy dating
• Describe the DE procedure steps and technique

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DE technique

• Dilatation and Evacuation (DE)
• A surgical method of abortion using a combination
  of cervical dilatation, suction aspiration and
  specialized forceps to assist in tissue
  evacuation.

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DE

• Appropriate for second-trimester abortion when
  trained, experienced clinicians are available and
  when
• Woman prefers a short process and/or an
  outpatient procedure
• Inpatient beds or facilities for overnight stay
  are limited or not available

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Counseling andInformed consent

• The client must understand
• Her clinical condition
• The risks/benefits of her clinical options
• Explain the abortion procedure
• What will happen, what she will feel
• Communicate effectively
• Use simple, clear language
• Consent should be voluntary and informed

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Special Cases

• Termination of a desired pregnancy
• More grief
• Sensitivity needed
• Fetal death in utero in the second-trimester
• Likely a desired pregnancy
• Causes of the loss?
• Increased risk of DIC if gt 4 weeks after fetal
  death in utero

(Maslow et al 1996)
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Medical History

• Past pregnancy/menstrual history
• Length of amenorrhea
• Allergies
• Medications
• Contraceptive use
• Previous surgery, especially uterine surgery

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Medical History

• Be aware of
• Active asthma
• Uterine fibroids
• Hypertension
• Epilepsy
• Previous cesarean section, cervical conization,
  myomectomy
• Previous postpartum hemorrhage
• Bleeding disorder

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Physical Exam

• Vital signs- blood pressure and pulse
• Abdomen
• Pelvic
• Cervical lesions
• Uterine size, position, masses

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Confirming Length of Pregnancy

• Errors in estimating gestational age cause
  problems
• Inaccurate dating complications
• Menstrual history
• Abdominal exam and pelvic exam
• Ideally, ultrasound should be used (biparietal
  diameter and femur length)

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Biparietal Diameter (BPD)
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Femur Length (FL)
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DE - Ten Steps

• Prepare instruments
• Prepare the woman
• Cervical antiseptic prep
• Administer paracervical block
• Dilate cervix
• Insert cannula
• Empty uterus with suction and forceps
• Inspect tissue
• Perform any concurrent procedures
• Process instruments and dispose of waste

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1. Prepare Instruments

• Check that aspirator retains vacuum
• Prepare more than one aspirator
• Make sure large dilators and DE forceps are
  sterile and available

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2. Prepare the Woman

• Prepare the cervix
• Administer 400 mcg misoprostol 3-4 hours before
  procedure
• Route
• Vaginal, placed high in posterior fornix, or
• Buccal, placed in cheek pouches (for 30 minutes
  and then swallowed)
• Monitor bleeding and pain
• Heavy vaginal bleeding and strong pain indicate
  she is ready for procedure (even if before 3-4
  hrs)
• Ensure pain medicine has been given

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If vaginal use, place misoprostol tablets deep
into posterior fornix
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Prepare the Woman

• Ask the woman to empty her bladder
• Help her onto the table
• Position drain bin or pan under table to catch
  all fluids
• Wash hands, put on gloves and personal barriers
• Ask if she is ready to start
• Perform bimanual examination
• Remove dirty gloves
• Put on sterile gloves

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3. Perform Cervical Antiseptic Prep

• Follow no-touch technique
• Insert speculum
• Wash upper vagina and cervix with
  antiseptic-soaked sponge

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4. Perform Paracervical Block

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5. Dilate Cervix, 6. Insert Cannula

• Pull outward with tenaculum to straighten
  cervical passage into the uterus
• Attempt insertion of 14 mm cannula through cervix
• If cannula passes with minimal force, continue
  with procedure

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Difficult dilatation

• If dilators do not go in easily, if adequate
  dilatation not achieved, do not proceed with the
  procedure
• More Misoprostol (400-600 mcg) is needed and
  additional waiting period
• Gentle dilatation is critical
• Risk of perforation increases if more than
  moderate force is required

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7. Empty Uterus

• Attach aspirator to cannula and aspirate amniotic
  fluid
• Rotate cannula, and gently move in and out as
  needed
• Remove cannula, empty syringe, re-establish
  vacuum and reinsert as needed until fluid is
  evacuated
• Maintain no-touch technique

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Aspirate the Amniotic Fluid
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Evacuate Uterus Use of Forceps

• Maintain traction on cervix
• Insert forceps in vertical position, so that jaws
  open up and down, not side to side
• Hold forceps with thumb against, but not through
  anterior ring
• As soon as forceps passes through internal os,
  open gently as wide as possible
• Close forceps to grasp tissue, rotate 90o and
  remove

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Use of Forceps
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Evacuation continued

• Be careful not to grasp myometrium
• During evacuation, re-grasp tissue as needed to
  reduce bulk
• Be sure to view cervix and not to tear it with
  forceps
• Most evacuations can be accomplished from the
  lower portion of the uterine cavity

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Evacuation continued

• Use suction to bring tissue down from uterine
  fundus as needed, alternating with forceps
• Avoid probing deep into uterus in horizontal
  position

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8. Inspect Tissue

• Empty contents of aspirator into container
• Strain tissue as needed
• Examine fetal tissue to be sure evacuation is
  complete
• Identify 4 extremities, thorax, spine, calvarium
  and placenta
• Exam of tissue is essential! An incomplete
  procedure may lead to hemorrhage and infection

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9. Perform Concurrent Procedures

• After tissue inspection is complete, wipe cervix
  with swab and assess bleeding
• Perform bimanual exam
• Perform concurrent procedures, e.g.
• Repair of any cervical tear
• IUD (intrauterine device) insertion
• Female sterilization

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10. Process Instruments and Dispose of Waste

• Cover fetal tissue
• Put all instruments into soaking solution
• Dispose of all needles appropriately
• Remove gloves and place in soaking solution or
  discard
• Wash hands
• Properly dispose of fetal tissue