Procedure Steps Using Ipas MVA Plus and Ipas Easy Grip

1. Procedure StepsUsing Ipas MVA Plus� and Ipas Easy Grip� 

2. Presentation Topics Ipas product overview MVA procedure steps Troubleshooting tips Test your knowledge

3. Ipas MVA Plus� and Ipas EasyGrip� Cannulae Woman-centered, appropriate technology Safe and effective Can be used in decentralized heath-care settings

4. Intended Use & Indications Treatment of incomplete abortion up to 12 weeks fromthe last menstrual period (LMP) First-trimester abortion (menstrual regulation) Endometrial biopsy

5. Ipas MVA Plus� Aspirator Plunger and O-ring: creates vacuum of 24-26 inches(609.6-660.4mm) of mercury Valve buttons: control release of vacuum Collar stop with retaining clip: keeps plunger in cylinder 60cc cylinder: holds aspirated tissue

6. Ipas EasyGrip� Cannulae Designed for use with the Ipas MVA Plus� aspirator Connect directly without need for separate adapter Manufacturer-sterilized with ethylene oxide(ETO) after packaging Must be sterilized or HLD before reuse Available in sizes 4-12mm Sizes are color-coded for easy reference Semi rigid, latex-free plastic

7. Ipas EasyGrip� Cannulae Cont Wings: Facilitate insertion and removal from aspirator Dots: At 1cm intervals to indicate location of aperture and fundus when inserted. Aperture: Sizes 4, 5, 6, 7 and 8mm have two opposing apertures. Sizes 9, 10 and 12mm have one larger, single-scoop aperture Affixed Base: Allows cannula to be connected directly to Ipas MVA Plus� aspirator. Color-coded by size for rapid differentiation.

8. Ipas 3mm Cannula Endometrial biopsy Infertility Abnormal uterine bleeding Amenorrhea Screening for endometrial infections and endometrial cancer Used with Ipas MVA Plus� aspirator Requires 6mm adapter Can be used alone with Ipas single-valve aspirator Single use

9. Selection of Cannulae Appropriate to uterine size and amount of dilation Using a cannula that is too small may result in retained tissue or loss of suction

10. Contraindications, Precautionsand Warnings Contraindications Endometrial biopsy should not be performed in cases of suspected pregnancy There are no known contraindications for treatment of incomplete abortion for uterine sizes up to 12 weeks LMP or first-trimester abortion (menstrual regulation) Precautions Treat any serious medical conditions that may be present Once patient is stabilized, do not delay aspiration Procedural difficulty may result with fibroids, anomalies and blood dyscrasia Warnings* Uterine or cervical injury/perforation Pelvic infection Vagal reaction Incomplete evacuation Acute hematometra

11. Steps for Performing MVA Prepare instruments Prepare the woman (including pain management plan) Perform cervical antiseptic prep Administer paracervical block Dilate cervix Insert cannula Aspirate uterine contents Inspect tissue Perform any concurrent procedures Process instruments

12. MVA Instruments

13. Steps for Performing MVA

14. Step 1. Instrument PreparationCreate Vacuum Begin with valve buttons open (not depressed) Plunger should be positioned all the way inside cylinder Collar stop should be locked in place, with tabs pushed down into holes in cylinder Push both valve buttons down and forward at same time until they lock into place (1.) Create vacuum by pulling plunger straight back until plunger arms snap outward and catch on wide sides of cylinder base (2.) Check for vacuum retention by letting aspirator sit for several minutes Push valve buttons to release vacuum

15. Check Vacuum Check for vacuum before each use Aspirator should sit for several minutes after establishing vacuum Push valve buttons to release vacuum A rush of air indicates vacuum was retained If a rush of air is NOT heard Displace collar stop Withdraw plunger Check that plunger O-ring is properly lubricated, properly positioned in groove, and free of damage and foreign material Make sure cylinder is firmly placed in valve Charge and test again* 

16. Step 2: Prepare the Woman Ensure pain medication is given at the appropriate time Drug must be most effective at the time of the procedure Administer drugs 30 to 45 minutes before the procedure Ask woman to empty her bladder Help her onto the table Ask for permission to start Put on barriers and wash hands Perform a bimanual exam

17. Pain Management During MVA Goal: reduce pain and anxiety, minimize risk Women�s responses to pain vary Plan should be created by woman and provider Factors to consider The woman�s needs and wants Her medical history and physical and psychological status Psychological concerns and potential anxiety Nature of the procedure to be done Any preexisting pain Resources available Site protocols for service delivery

18. Three Sources of Pain During MVA Psychological pain: anxiety, fear, apprehension Cervical pain due to dilatation Uterine cramping due to manipulation

19. Non-Pharmacological Methods Gentle, respectful interaction and communication Encourage her to relax and breathe deeply Verbal support and reassurance Appropriate touch: hold her hand, rub her arm Gentle, smooth operative technique Offer the support she requested Talk or silence Advance notice of each step These methods can supplement but not replace medications

20. Pharmacologic Methods Addressing Pain Psychological pain Anxiolytics/sedatives relieve anxiety Analgesics relieve pain General anesthesia should be reserved for extreme cases Cervical pain due to dilatation Anesthetic: paracervical block using lidocaine Analgesics: i.e. nonsteroidal anti-inflammatory drugs (NSAIDs) Uterine cramping due to manipulation Analgesics: i.e. NSAIDs

21. Wear Barriers for MVA Procedures

22. Perform Bimanual Exam

23. Step 3: Perform Cervical Antiseptic Prep Follow no-touch technique Use antiseptic sponges to clean Cervical os Cervix Vaginal walls Do not retrace areas previously cleaned

24. No-Touch TechniqueReminder It is possible to introduce pathogens when passing an instrument into the uterine cavity No instrument that enters a woman's uterus should come into contact with a contaminated surface before insertion through her cervix Tenaculum, cannula and dilator tips should not touch the provider's gloves, the woman's vaginal walls, or unsterile (or non-HLD) parts of the instrument area

25. Antiseptic Cervical Prep

26. Step 4: Administer Paracervical Block Recommended for all MVA procedures Injection sites vary but technique accepted globally Usually 10�20mL of 0.5%�1.0% lidocaine Always < 200mg Always aspirate needle before injecting

27. Administering Paracervical Block Inject 2mL of lidocaine where tenaculum will be placed Place tenaculum at anesthetized site Apply slight traction to move cervix, exposing transition from smooth cervical epithelium to vaginal tissue Compared to cervical tissue, vaginal mucosa is more elastic and appears folded This transition marks the site for further injections around the cervix (paracervical) Slowly inject 2�5mL of lidocaine on the side of the cervix at 4 and 8 o�clock Inject to a depth of 1 � 1.5 inches or 25 � 38 mm Use slow technique to minimize discomfort

28. Steps of Paracervical Block Place the needle where the tenaculum will be placed at 12 o�clock (alternate at 6 o�clock) Aspirate needle to avoid injecting into a blood vessel Inject 2mL of lidocaine �Place the tenaculum at the anesthetized site Use slight traction to move the cervix Define the transition from the smooth cervical epithelium to vaginal tissue Compared to cervical tissue, vaginal mucosa is more elastic and appears folded. This transition marks the site for further injections around the cervix (paracervical) Place the needle, and aspirate before injecting 2 � 5 mL of lidocaine on the side of the cervix at 4 o�clock Inject to a depth of 1 � 1.5 inches or 25 � 38 mm, using slow technique to minimize discomfort Apply gentle traction to move the cervix Place the needle, and aspirate before injecting 2 � 5 mL of lidocaine on the side of the cervix at 8 o�clock Inject to a depth of 1 � 1.5 inches or 25 � 38 mm, using slow technique to minimize discomfort

29. Paracervical Block

30. Step 5: Dilate Cervix Dilatation required in most but not all cases Cannula should fit snugly in os to hold vacuum Use gentle operative technique Use progressively larger cannulae Can use mechanical dilators, laminaria or misoprostol

31. Selection of Cannulae Appropriate to uterine size and amount of dilation Using a cannula that is too small may result in retained tissue or loss of suction

32. Step 6: Insert Cannula Gently apply traction to the cervix Rotate the cannula while gently applying pressure Insert cannula slowly until it touches the fundus, then draw it back Alternatively, insert cannula just past internal os

33. Insert Cannula Into Uterus

34. Attach Aspirator

35. Step 7: Aspirate Uterine Contents Attach charged aspirator to cannula Release buttons to start suction Gently rotate cannula 180 degrees in each direction Use a gentle �in and out� motion Do not withdraw cannula opening beyond external os

36. Release Buttons

37. Evacuate Uterine Contents

38. Signs That the Uterus Is Empty Red or pink foam, without tissue, passing through cannula Gritty sensation felt against the cannula Uterus contracting around cannula Increased uterine cramping

39. When the Procedure Is Finished Push buttons down and forward to close valve Disconnect cannula from aspirator OR remove cannula from uterus without disconnecting Ipas EasyGrip� cannulae fit firmly into the valve of the aspirator. Use care when disconnecting cannula from the aspirator After tissue inspection, re-evacuation may be necessary

40. Detach Cannula From Aspirator

41. Step 8: Inspect Tissue Empty contents of aspirator into container Look for POC Villi and decidua should be visible Evaluate amount of POC based on estimated length of gestation Determine that all POC have been evacuated Strain POC Float in water View with light underneath

42. Tissue Inspection*

43. Step 9: Perform Any Concurrent Procedures If POC inspection satisfactory Wipe the cervix with swab to assess additional bleeding Perform bimanual exam to check uterine size and firmness, if advised Perform concurrent procedure

44. Step 10: Process Instruments Soak or discard instruments immediately

45. Ipas MVA Plus� Aspirator Processing Options

46. Processing for Optimal Infection Prevention Instruments should be processed using the available methodthat provides the highest level of effectiveness When best practices are followed, the following methods arelisted in order of effectiveness: 1) Sterilization using steam autoclave or Sterrad processor 2) Sterilization using cold methods (i.e. Cidex, Sporox II) 3) HLD methods (boiling, chlorine, cold methods)

47. Post-Procedure Care Reassure woman that the procedure is finished Help her into a comfortable position Ensure she is escorted to the recovery area Physical monitoring Pain management Provision of antibiotics Addressing other health issues Emotional monitoring and support Contraceptive counseling Schedule follow-up care Provide discharge instructions

48. Troubleshooting Tips Reasons for decrease in MVA vacuum What to do when the aspirator is full When the cannula is withdrawn past os When the cannula is clogged If the aspirator does not hold a vacuum

49. Reasons for Decrease in MVA Vacuum Troubleshooting Tip Aspirator is full Cannula is withdrawn past os Cannula is clogged Aspirator is incorrectly assembled

50. When Aspirator Is Full Troubleshooting Tip Close valve buttons Detach cannula and leave in os Open the valve buttons Squeeze plunger arms Push plunger and empty aspirator Establish new vacuum Reattach aspirator to cannula in os and continue

51. When Cannula Is Withdrawn Past Os Troubleshooting Tip Remove cannula and aspirator Do not touch vaginal walls Detach and empty aspirator Reestablish vacuum Reinsert cannula if it has not been contaminated; if contamination has occurred, insert another sterile or HLD cannula using no-touch technique Reconnect cannula to aspirator Release valve buttons and continue aspiration

52. When Cannula Is Clogged Troubleshooting Tip Ease cannula back toward, but not through, the external os OR Depress valve buttons and withdraw aspirator and cannula out of uterus Remove tissue clogging cannula using sterile or HLD forceps Reinsert cannula and continue aspiration Never push tissue through cannula while still in uterus

53. If Aspirator Does Not Hold Vacuum Troubleshooting Tip Displace collar stop Withdraw plunger Check that plunger O-ring is properly lubricated, properly positioned in groove, and free of damage and foreign material Make sure cylinder is firmly placed in valve Reassemble and test aspirator Important: If vacuum is still not retained, discard and use another aspirator

54. Test Your Knowledge

55. What are possible sources of pain for women undergoing UE with MVA? Anxiety Fear Cervical dilatation Uterine cramping All of the above The correct answer is E. All of the aboveThe correct answer is E. All of the above

56. No-touch technique refers to..? The provider not touching the patient without wearing gloves The patient not touching the provider Using other instruments to pick up sterile instruments rather than gloved hands Making sure that parts of instruments that enter the uterus do not touch objects or surfaces that are not sterile (including vaginal walls) before being inserted The correct answer is D. Making sure that parts of instruments that enter the uterus do not touch objects or surfaces that are notsterile (including vaginal walls) before being inserted The correct answer is D. Making sure that parts of instruments that enter the uterus do not touch objects or surfaces that are notsterile (including vaginal walls) before being inserted

57. What of the following signs suggest that the evacuation is complete..? The uterus is felt contracting around the cannula A gritty sensation is felt against the cannula Red or pink foam, without tissue, passes through the cannula Increased uterine cramping All of the above The correct answer is E. All of the aboveThe correct answer is E. All of the above

58. A decrease in vacuum may occur before the aspiration is complete because..? The aspirator is full The cannula is clogged The cannula is withdrawn past the external os All of the above None of the above The correct answer is D. All of the aboveThe correct answer is D. All of the above

59. The contents of the uterus are evacuated by gently rotating the cannula..? 180 degrees using an up and down motion 180 degrees using an in and out motion 90 degrees using an up and down motion 90 degrees using an in and out motion The correct answer is B. 180 degrees using an in and out motion The correct answer is B. 180 degrees using an in and out motion