Suction evacuation / MTP (first trimester)

Patient and case

1. Name / Age / Sex
2. UHID / IP no. / Ward-Bed
3. Date of surgery / OT no.
4. CaseElectiveEmergency (non-elective)if emergency, state urgency and reason
5. Timesin OT ___ anaesthesia start ___ incision ___ closure ___ out of OT ___

Team

1. Operating surgeonname, designation
2. Assistant(s)
3. Supervising consultantpresent in OT / available / not applicable
4. Steps done by the residentwhole procedure / named steps, under whose supervision
5. Anaesthetist
6. Scrub nurse / circulating nurse

Diagnosis and procedure

1. Pre-operative diagnosis
2. Post-operative diagnosis
3. Procedure planned
4. Procedure performedif different from plan, state why
5. Extra procedure done and reason'none' if none. Only to save life or health if not consented

Consent and safety checks

1. Informed consentGeneralProcedure-specificHigh-riskAnaesthesiain a language the patient understands: language ___ witness ___
2. Site / side markedYesNot applicable
3. WHO Surgical Safety ChecklistSign inTime outSign out
4. Antibiotic prophylaxisdrug, dose, route, time given before incision
5. VTE prophylaxisMechanicalPharmacologicalNot indicated

Risks to explain in the consent for this operation

• bleeding, rarely needing transfusion
• incomplete evacuation needing a repeat procedure
• failed abortion with continuing pregnancy
• uterine perforation, which may need laparoscopy or laparotomy
• cervical tear from the tenaculum or dilators
• infection of the uterus
• collection of blood in the uterus (haematometra) needing repeat aspiration
• ectopic pregnancy missed if no villi are seen

Pre-operative details for this operation

1. Gestational ageby LMP and by ultrasound (CRL in mm); write both
2. Ultrasound: intrauterine pregnancy confirmedYes, single liveYes, non-viableNot done: reasondate of scan
3. Ground for termination under the MTP ActRisk to life of the womanGrave injury to physical or mental healthContraceptive failurePregnancy alleged to be from rapeSubstantial risk of fetal abnormality
4. MTP paperworkForm C consent signed (by guardian if minor or mentally ill), Form I opinion filled, Admission Register serial number
5. Hb and blood group with Rh type
6. Cervical preparationNoneMisoprostol 400 mcg buccal / vaginal: time givenOsmotic dilator
7. Prophylactic antibioticdrug, dose, time (e.g. doxycycline 100 mg oral before the procedure)
8. Post-abortion contraception chosenTubal ligation (separate sterilisation consent)IUCDOCPInjectableOtherNone
9. Bladder emptied before procedureVoidedCatheterised

Anaesthesia and position

1. AnaesthesiaParacervical blockParacervical block with IV sedationGeneral (short IV)drug, strength and total volume of local anaesthetic; keep lignocaine within 5 mg/kg or 200 mg, whichever is less
2. PositionDorsal lithotomy

Operative findings

1. Bimanual examination before startinguterine size in weeks, position (anteverted / retroverted), mobility, adnexa
2. CervixClosedSoft, admits dilator
3. Dilated up todilator type and size (Hegar mm / Pratt F)
4. Products of conceptionapproximate amount, villi and sac seen on floating in saline / water, fetal parts if 10 weeks or more
5. End-pointGritty feel in all walls, pink froth in cannula, uterus contractedUncertain: rechecked

Procedure (steps)

1. Parts painted and drapedantiseptic used
2. Speculum inserted, cervix cleaned
3. Tenaculum / vulsellum appliedAnterior lipPosterior lip (retroverted uterus)
4. Paracervical blockdrug, volume, sites (e.g. 12 o'clock for tenaculum then two or more sites at the cervicovaginal junction)
5. Cervical dilatationdilator set used and final size; sounding not routinely needed
6. Method of aspirationManual vacuum aspiration (MVA)Electric vacuum aspiration (EVA)cannula size in mm (usually equal to weeks of gestation, plus or minus 1)
7. Aspirationrotary and in-and-out movement, number of passes, syringe emptied between passes
8. Completion checkedGritty feel and frothSmaller cannula re-passUltrasound
9. Uterotonic (if given)drug, dose, route, time
10. Aspirate examinedrinsed and floated; villi / sac / fetal parts identified or not
11. Tenaculum removed, bleeding from tenaculum site checked
12. Post-abortion IUCD / tubal ligation (if chosen)device and batch, or refer to separate sterilisation note

Closure, drains and dressing

1. Cervix and vagina inspectedNo tearTear sutured: suture used
2. Vaginal packNonePlaced: remove at (time)
3. Bleeding at endMinimalModerateHeavy: action taken

Specimens and implants

1. Products of conceptionSent for HPE in formalinNot sent: disposed of as human anatomical waste with copy of MTP certificatesend for HPE if villi not clearly seen or molar change suspected
2. IUCD insertedtype, lot/batch number, sticker

End of procedure

1. Estimated blood lossml
2. IV fluids and blood / products givenfluids (ml); blood: type, units, bag nos.
3. Swab, needle and instrument countCorrectIncorrect: action taken
4. Intra-operative complications / difficultieswhat happened and what was done; 'none' if none
5. Implant stickersNo implantAffixed in case sheet, OT register and for discharge summary
6. Condition at end of surgery / shifted toPACUWardICU/HDU

Post-operative orders

1. Vitals and vaginal bleedingpulse, BP and pad check at set intervals till discharge (write the interval)
2. Painsevere cramps within 2 hours with little bleeding: examine for haematometra; severe persistent pain: think of perforation
3. Analgesiadrug, dose, frequency
4. Antibioticsecond dose if ordered (drug, time)
5. Anti-Dif Rh negative: 50 mcg IM before 13 weeks, 300 mcg at 13 weeks or later
6. Oral intakesips and liquids when awake
7. Dischargewhen stable, bleeding minimal, passed urine, walking
8. Warning signs explainedheavy bleeding, fever, foul discharge, severe pain
9. Follow-update; HPE result if sent; urine pregnancy test or beta-hCG if villi were not seen
10. Contraceptionmethod started or planned

Signature

1. Name and designation of person writing note
2. Medical Council registration no.
3. Signature / date / time of writingwrite before the patient leaves recovery