STEPS FOR UTERINE ASPIRATION

1. Review clinical history, EGD, US, labs (if any), & consents (procedure, sedation, contraception).
2. Introduce yourself (and trainee or trainer – see Ch. 11: Consent for Trainee Participation in Abortion Care), establish rapport, elicit and answer any questions. “What questions do you have for me?”
3. Provide reassurance and details to the extent the person desires.
4. Assess vitals, perform time-out.
5. If using vaginal misoprostol for cervical prep (generally > 10-12 weeks; See Ch. 5), insert or invite self-insertion, then restart the procedure after allotted time with a quick review of steps 1-4.
6. Administer IV medications, if using.
7. Don gloves (and other personal protective equipment as necessary).
8. Prepare equipment tray and all items for procedure; adjust the table and light.
9. Provide verbal guidance to position the patient.
10. Perform a bimanual exam (BME) as needed, to confirm uterine position and size.
11. Place speculum, evaluate cervix and vagina, collecting samples as needed (e.g. STI).
12. Apply antiseptic solution to the cervix, if using.
13. Administer paracervical anesthesia: make a wheal at 12 or 6 o’clock (depending on uterine position), place the tenaculum, closing slowly and quietly, and administer the paracervical block. Track the person’s pain level throughout the procedure, stopping to address pain as needed.
14. Exert gradual traction, as needed, to straighten cervical canal.
15. Gently dilate the cervix sequentially up starting with a small dilator (5-6mm or 15 Fr), to appropriate  cannula size [gestational duration in weeks (+/- 1 to 2 mm)], advancing dilators beyond internal os, but not to uterine fundus.
    1. With tenaculum traction, gently explore the cervical canal, holding the dilator loosely, allowing rotation within the canal (should have a smooth, mucosal feel, with internal os “giving way” to gentle, steady pressure). If meeting resistance or unable to pass through the internal os, consider the following options:
       • Gently apply more traction on the tenaculum to further straighten the canal.
       • Change the dilator angle, dropping your wrist, or switch between Pratt and Dennison dilators, to a flexible plastic sound or os finder.
       • Reposition person to create more hip flexion
       • Change the tenaculum location (placing on posterior lip for a retroflexed uterus)
       • Use transabdominal ultrasound guidance
       • Repeat pelvic exam
       • Open the speculum more, or consider a shorter or wider (or Klopfer) speculum, if available
       • Place misoprostol 400 mcg PV; reattempt dilation in 1- 3 hours (WHO 2022).
16. Advance cannula into uterus while maintaining traction on the tenaculum.
17. Connect aspirator (manual or electric) to cannula and suction to remove all pregnancy tissue by rotating the cannula and withdrawing to the internal os, readvancing and repeating until there are signs the uterus is empty (see Table below).
18. If the person desires IUD placement, ask if they prefer the speculum remain or be removed while you examine the pregnancy tissue.
19. Ensure uterine tone and minimal bleeding prior to speculum removal (or IUD placement).
20. Check products of conception (POC) for adequacy. See Ch 2 for discussion of patient-centered viewing practices.
21. Reassure the person of the complete procedure, that things went smoothly. “I saw everything I needed to see and you are no longer pregnant.” Reassure that cramps are a sign of a healthy uterus returning to its non-pregnant size, that emotions arising with abortion are normal, and that you and staff are there with them.
22. See Troubleshooting below if unable to confirm completion.
23. Place a contraceptive implant or IUD, if desired by the person.
24. Initiate the recovery process.