This protocol provides basic requirementsThis was designed for states with fewer restrictions on abortion care. This protocol should be modified to reflect individual state restrictions as needed. for implementing MVA services at a family medicine teaching site. This interactive version also includes pop-up citations and practice tips. A print-ready/PDF version of the protocol is also available.

Manual Vacuum Aspiration (MVA) Protocol

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Scheduling

Patients requesting appointments for abortion should be scheduled as soon as possibleIn settings where this information is not possible to obtain during the appointment request, consider getting a patient call-back number so a qualified staff member can contact the patient to clarify details ahead of the appointment. but no later than 7 days after appointment request. If no appointments are available, a provider should be consulted

Patient Eligibility

Most patients presenting for abortions are young and healthy and most family medicine practices will only provide abortion procedures with a manual vacuum aspirator (MVA). This protocol is designed for procedures performed in these environments. You may want to consider an alternative location or special preparations if:

• The gestational age is over 10 weeksOptimally, a patient at >10 weeks gestation would receive an abortion in a location that has EVA available. If you don’t have this option, then having an extra staff member in the room with a backup MVA is preferred.
• The patient has a bleeding disorderOptimally, the patient would be in a location that has monitoring or support in the unlikely event of a hemorrhage. or is taking anticoagulant medication. 
• The patient has BP >180/120 and is symptomatic.Elevated blood pressure with symptoms such as chest pain, dyspnea or neurologic deficit might indicate a hypertensive emergency and requires immediate attention. Asymptomatic patients with elevated blood pressure should be able to proceed with the uterine aspiration with office management of the blood pressure.
                           
Also see:
                           
Hackett, C. et al. What is urgent about hypertensive urgency? Can Fam Physician. 2017 Jul; 63(7): 543. PMCID: PMC5507232
                           
Alley WD and Copelin II EL. Hypertensive Urgency. SourceStatPearls. Treasure Island (FL): StatPearls Publishing; 2018-2018 Jul 12.

Staffing/Clinic Coverage

A medical provider needs to be credentialed prior to performing MVA procedures. Residents may only perform an MVA if a credentialed physician is present during the procedure.

In addition to the credentialed medical provider performing the MVA, an additional person, such as a medical support person (LPN, PCT, MA, etc.), must be available in the room during the procedure. A family member may be present but does not replace the need for one of the above personnel.

The medical support person can have the role(s) of:

• Witnessing the consent form
• Retrieving instruments or supplies as needed during the procedure
• Helping to keep the patient stable during a vasovagal or vomiting episode
• Providing additional emotional support for the patient

A learner (resident, medical/nursing student, etc.) may be involved in the procedure only if the patient agrees to their participation. If a learner is present, an additional LPN/PCT/MA support person may not be needed. Recommended roles for learners include:

• Medical students/NP students: observation only
• Medical residents: observation and hands-on training. The Aspiration for Abortion Assessment Tool may be used to evaluate the resident’s competence.

Storage Space

An instrument cart can be used for storage of both instruments and devicesIn many institutions, devices must be kept locked with medications. Refer to your institution’s policies and practices.. The cart can also serve as a surface for instruments during the procedure. The cart should remain locked when not in use. Sterilized instruments can be pre-packed and kept in the instrument cart along with devices and other necessary supplies.

No-Touch Technique

Preventing infection is an important goal during a uterine aspiration. During the procedure, the provider and staff will use a “no-touch” techniqueFor more information on the technique, see this chapter from TEACH’s Early Abortion Training Workbook. to handle the instruments. This means having supplies on a sterile tray, keeping sterile and non-sterile instruments separate, and handling instruments in a way that avoids contact with the tips that enter the uterus.

List of Supplies

Single-use Items
Re-usable items
Medications
Vaginal antisepticThere are ongoing studies evaluating the necessity of routine vaginal antiseptics before MVAs. See:
                           
Achilles SL and Reeves MF. Prevention of infection after induced abortion. Contraception. 2011 Apr;83(4):295-309. doi: 10.1016/j.contraception.2010.11.006. Epub 2011 Feb 12.
and applicator
Metal speculaSterile disposable specula are also available and work well with fiber optic lights. Although this is a no-touch procedure, having a sterile speculum is important for learners who might not yet be steady with their hands. in multiple sizes
lidocaine 1% for paracervical block
Sterile drape for tray
Serrated ring forceps

ibuprofenMany providers offer a pre-procedure dose of 400-800mg 30 minutes prior to start. There are conflicting data about its efficacy in reducing pain during the procedure, however it reduces post-procedure discomfort and may allow patients to go home sooner. Also see:
                           
Allen RH, Singh R. Society of Family Planning clinical guidelines: pain control in surgical abortion part 1 – local anesthesia and minimal sedation. Contraception. 2018 Jun;97(6):471-477. doi: 10.1016/j.contraception.2018.01.014.

Syringes (10cc x 2Or 20cc x 1) and Needle (21 or 22 gauge, 1.5 inch)

Single-tooth tenaculumAtraumatic or multi-tooth tenaculum should also be available.

misoprostolMisoprostol can be used prior to the procedure for cervical preparation (dose 400mcg vaginally 3-4 hours prior to 1st trimester procedure or 600mcg bucally 90 minutes prior to 2nd trimester procedure) or for management of significant post-prodcedure bleeding (dose 800-1000mcg, sublingual or bucal administration preferable to rectal). See:
                           
Allen R, O’Brien B. Uses of Misoprostol in Obstetrics and GynecologyRev Obstet Gynecol. 2009 Summer; 2(3): 159–168. PMCID: PMC2760893 PMID: 19826573
                           
Kerns J, Steinauer J. Management of postabortion hemorrhage: release date November 2012 SFP Guideline #20131. Contraception. 2013 Mar;87(3):331-42. doi: 10.1016/j.contraception.2012.10.024. Epub 2012 Dec 4.

Cannulas (plastic, flexible and/or rigid) up to 12 weeks size
Pratt dilatorsThe metal Pratt dilators are easier to maintain and sterilize than the plastic Denniston dilators.
(sizes 13/15, 17/19, 21/23, 25/27, 29/31, 33/35)
doxycyclineMost providers use a dose of 200mg doxycycline prior to procedure onset. If unavailable or patient has allergy the alternative medication would be azithromycin or metronidazole. See:
                           
Low N et al. Perioperative antibiotics to prevent infection after first-trimester abortion.Cochrane Database Syst Rev. 2012 Mar 14;(3):CD005217. doi: 10.1002/14651858.CD005217.pub2.
                           
Achilles SL, Reeves MF. Prevention of infection after induced abortion: release date October 2010: SFP guideline 20102. Contraception. 2011 Apr;83(4):295-309. doi: 10.1016/j.contraception.2010.11.006. Epub 2011 Feb 12.
Sterile Gauze 4×4
Several MVA syringes and lubricant (put together and tested before each use)
methergineThis medication is also frequently used to manage significant post-procedure bleeding but requires refrigeration. The dose is 0.2mg IM or IV. See:
                           
Kerns J, Steinauer J. Management of postabortion hemorrhage: release date November 2012 SFP Guideline #20131. Contraception. 2013 Mar;87(3):331-42. doi: 10.1016/j.contraception.2012.10.024. Epub 2012 Dec 4.

(optional)
Gloves/Sterile gloves for tray setup
Strainer and pyrex dishKitchen varieties acceptable. (to evaluate POCs)
Light source
Sterile lubricating gel
Chux
GC/C, pap if needed
Sealed specimen cup with formalin
Kidney basin (disposable or metal)

 

Sample Tray Setup for MVA

Useful Documents

• Institutional consent form
• Early Abortion Comparison Chart (English and Spanish)
Information for Patients after Aspiration Abortion

On the day of the abortion:

“Time Out” Protocol:

Consult with your institution to determine whether it is required to follow Joint Commission regulations regarding “time out”See:
                           
Barsuk JH et al. Process Changes to Increase Compliance With the Universal Protocol for Bedside Procedures. Arch Intern Med. 2011;171(10):941–954. doi:10.1001/archinternmed.2011.202
                           
Pellegrini CA. Time-outs and their role in improving safety and quality in surgery. Bull Am Coll Surg. 2017 Jun;102(6):54-6. PMID: 28885812
                           
The Joint Commission, National Time Out Day increases awareness on supporting safety culture, safe practices in OR. Accessed 2/26/2019.
prior to a procedure. Obtaining the consent in the presence of the involved staff may serve as an appropriate substitute. Otherwise, “time out” may include verifying the patient’s name and DOB prior to the procedure.

Document the patient encounter per clinic protocol.

 
See Aspiration for Abortion Assessment Tool for detailed steps of the procedure.
 

Evaluation of Products of Conception (POCs)

Even if sending to pathology, inspection of POCs is integral to the procedure. Determine who will be evaluating the POCs and where this will be done.

Ask the patient if they want to see POCs.

Before the patient leaves:

• Post-procedural VS taken
• Ensure the patient has a way to contact the provider/clinic
• Ensure the patient has received the aftercare information
• Confirm the patient has taken the doxycycline
• Confirm any additional testingDepending on the case, the patient may need a follow up HCG or sonogram. was ordered/done

Cleanup per clinic protocol

 

Management of Reusable MVA Instruments

Institutions have different policies and procedures for sterilization of instruments. Typically, a trained staff member will soak dirty instruments in enzymatic cleaner, scrub any visually bloody areas, and then rinse the instruments, and let them air-dry. All used, dirty medical instruments must be kept in a “dirty” area of a room. Once dry, the instruments need to autoclaved on-site or sent out for autoclaving.

Autoclaving on-site:
• Document training and certification in sterilization/infection control procedures.
• Maintenance of a log for machine runs, cleaning schedule, weekly spore test/biologic indicator results.

Sterile instruments may be kept in the instrument cart.