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Department of Reproductive Health and Research (RHR), World Health Organization

Managing Complications in Pregnancy and Childbirth

A guide for midwives and doctors 

 


Section 3 - Procedures


Dilatation and curettage

The preferred method of evacuation of the uterus is by manual vacuum aspiration. Dilatation and curettage should be used only if manual vacuum aspiration is not available.

  • Review for indications.

  • Review general care principles.

  • Provide emotional support and encouragement and give pethidine IM or IV before the procedure. If necessary, use a paracervical block.

  • Administer oxytocin 10 units IM or ergometrine 0.2 mg IM before the procedure to make the myometrium firmer and reduce the risk of perforation.

  • Perform a bimanual pelvic examination to assess the size and position of the uterus and the condition of the fornices.

  • Apply antiseptic solution to the vagina and cervix (especially the os).

  • Check the cervix for tears or protruding products of conception. If products of conception are present in the vagina or cervix, remove them using ring (or sponge) forceps.

  • Gently grasp the anterior lip of the cervix with a vulsellum or single-toothed tenaculum (Fig P-32).

Note: With incomplete abortion, a ring (sponge) forceps is preferable as it is less likely than the tenaculum to tear the cervix with traction and does not require the use of lignocaine for placement.

  • If using a tenaculum to grasp the cervix, first inject 1 mL of 0.5% lignocaine solution into the anterior or posterior lip of the cervix which has been exposed by the speculum (the 10 o’clock or 12 o’clock position is usually used).

  • Dilatation is needed only in cases of missed abortion or when some retained products of conception have remained in the uterus for several days:

- Gently introduce the widest gauge cannula or curette;

- Use graduated dilators only if the cannula or curette will not pass. Begin with the smallest dilator and end with the largest dilator that ensures adequate dilatation (usually 10–12 mm) (Fig P-33);

- Take care not to tear the cervix or to create a false opening.

Figure P-32

 Inserting a retractor and holding the anterior lip of the cervix

 

  Figure P-33

  Dilating the cervix

 

  • Gently pass a uterine sound through the cervix to assess the length and direction of the uterus.

The uterus is very soft in pregnancy and can be easily injured during this procedure. 

  • Evacuate the contents of the uterus with ring forceps or a large curette (Fig P-34). Gently curette the walls of the uterus until a grating sensation is felt.

Figure P-34

 Curetting the uterus 

  • Perform a bimanual pelvic examination to check the size and firmness of the uterus.

  • Examine the evacuated material. Send material for histopathological examination, if required.

POST-PROCEDURE CARE

- prolonged cramping (more than a few days);

- prolonged bleeding (more than 2 weeks);

- bleeding more than normal menstrual bleeding;

- severe or increased pain;

- fever, chills or malaise;

- fainting.

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Clinical principles

Rapid initial assessment

Talking with women and their families

Emotional and psychological support

Emergencies

General care principles

Clinical use of blood, blood products and replacement fluids

Antibiotic therapy

Anaesthesia and analgesia

Operative care principles

Normal Labour and childbirth

Newborn care principles

Provider and community linkages

Symptoms

Shock

Vaginal bleeding in early pregnancy

Vaginal bleeding in later pregnancy and labour

Vaginal bleeding after childbirth

Headache, blurred vision, convulsions or loss of consciousness, elevated blood pressure

Unsatisfactory progress of Labour

Malpositions and malpresentations

Shoulder dystocia

Labour with an overdistended uterus

Labour with a scarred uterus

Fetal distress in Labour

Prolapsed cord

Fever during pregnancy and labour

Fever after childbirth

Abdominal pain in early pregnancy

Abdominal pain in later pregnancy and after childbirth

Difficulty in breathing

Loss of fetal movements

Prelabour rupture of membranes

Immediate newborn conditions or problems

Procedures

Paracervical block

Pudendal block

Local anaesthesia for caesaran section

Spinal (subarachnoid) anaesthesia

Ketamine

External version

Induction and augmentation of labour

Vacuum extraction

Forceps delivery

Caesarean section

Symphysontomy

Craniotomy and craniocentesis

Dilatation and curettage

Manual vacuum aspiration

Culdocentesis and colpotomy

Episiotomy

Manual removal of placenta

Repair of cervical tears

Repair of vaginal and perinetal tears

Correcting uterine inversion

Repair of ruptured uterus

Uterine and utero-ovarian artery ligation

Postpartum hysterectomy

Salpingectomy for ectopic pregnancuy

Appendix

 

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