1. Review patient history, gestational age, & consents (procedure, sedation, contraception).
  2. Introduce yourself (and trainee or trainer), establish rapport, elicit and answer patient’s questions: “What questions do you have for me?” Provide reassurance and details to extent the patient desires.
  3. Assess vitals, perform time-out, and administer IV medications.
  4. Don gloves, mask, and protective eyewear (+/- gown, shoe covers). Prepare equipment tray and all items for procedure (cannula, block, etc.); adjust table and light.
  5. Perform bimanual exam (BME) to confirm uterine position & size. May not need if using US guidance.
  6. Insert the speculum, evaluate, and collect samples as needed for screening / testing (STI, pap).
  7. If using, apply antiseptic solution to cervix.
  8. Administer paracervical block. Assess patient’s pain level throughout procedure.
  9. Place tenaculum at 12 or 6 o’clock (depending on position of uterus); close slowly. Exert gradual traction to straighten cervical canal.
  10. Dilate cervix to size of cannula you will be using [gestational age in weeks (+/- 1-2 mm)]
    1. With traction on the tenaculum, gently explore canal, holding dilator loosely and allowing it to rotate within canal (should have a snug smooth, mucosal feel).
      • You may feel the internal os “give way” to gentle, steady pressure
    2. If unable to pass through the internal os, try the following:
      • Gently apply traction on tenaculum to straighten canal.
      • Change angle of dilator, dropping wrist, or switch to flexible plastic sound or os finder.
      • Reposition patient with hips further off table or on rolled towel to create more hip flexion.
      • Change tenaculum location (placing on posterior lip for a retroflexed uterus).
      • Use transabdominal US guidance.
      • Repeat pelvic exam.
      • Consider shorter, wider (or Klopfer) speculum if available. Try widening blades.
      • Provide misoprostol (sublingual/vaginal/buccal) and reattempt dilation in 1.5 – 3 hours.
  11. Advance cannula to just inside internal os using gentle firm traction on the tenaculum.
  12. Connect aspirator (MVA or EVA) to cannula, and empty uterus until signs that it is empty (see below).
  13. After confirming products of conception (POC) are complete, place IUD or implant if desired by patient.
  14. Remove tenaculum, assure minimal bleeding, and remove speculum.
  15. Check POC for adequacy, if not already done. Inform patient of complete procedure & recovery process


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