Emergency Treatment Module 2 - Session 4 Sharp Curettage by NIQe3C

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									Emergency Treatment
  Module 2 - Session 4
   Sharp Curettage
WHO recommends vacuum aspiration as the preferred
method for uterine evacuation before 12 weeks of pregnancy.




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Module 2 - Session 4
Objectives

  At the end of this session, participants will be able to:
  1. Identify the instruments used for D&C and sharp curettage
     procedures
  2. Explain the procedure for D&C and sharp curettage and
     demonstrate it on a model
  3. Describe the post-procedure care




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Sharp Curettage: Also Known as Dilatation and
Curettage (D&C)

  • Sharp curettage (SC) is an effective method for the treatment of
    incomplete abortion.
  • WHO recommends that sharp curettage be used only when
    vacuum aspiration (VA) is not available.
  • Reasons why many countries still rely on sharp curettage:
    – May experience difficulty in obtaining and maintaining VA
       supplies and equipment
    – Provider resistance to switching from sharp curettage
    – Providers may not have received training in VA
    – Some women presenting for PAC services are outside of the
       established criteria for VA use




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Sharp Curettage (2)

  When vacuum aspiration is not available (electric, foot pump
  or manual):
  • High-quality sharp curettage care must be ensured:
     – Periodic updating of skills is necessary as with any other
        surgical intervention.
  • Sharp curettage can be performed safely without general
     anesthesia.
  • Family planning counseling and services must be provided just
     as with clients receiving VA treatment.




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Instruments and Supplies for Sharp Curettage

  • Sterile equipment:
    – Retractor or speculum
    – Single-toothed tenaculum or vulsellum
    – Graduated dilators
    – Uterine sound
    – Curette or ring forceps
  • Local anesthesia
  • Antiseptic solution (e.g., Betadine)
  • Sterile gloves and infection prevention supplies/equipment




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Metal Curette

  Metal curette shown at front and side angles




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Steps for Sharp Curettage

  1. Review indications for use:
     – Inevitable or incomplete abortion
     – VA not available for incomplete abortion up to 12 weeks
       gestation
     – Incomplete abortion >12 weeks gestation
  2. Assess and determine treatment plan:
     – Greet and assess client.
     – Confirm the diagnosis and note any additional complications.
     – If needed, stabilize client and begin treatment of
       complications.
     – Assess pain management needs.
     – Discuss analgesia/anesthesia options.
     – Obtain any required informed consent before any medication
       or anesthesia is administered.
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Steps for Sharp Curettage (2)

  3. Counsel the patient on the procedure, provide emotional
     support and encourage the patient throughout the procedure.
  4. Organize the procedure area for SC:
     – Establish sterile field.
     – Organize instruments and equipment:
       • Forceps, speculum, tenaculum, sound, dilators, curettes
          of varying sizes if available
       • Other instruments according to anticipated need (e.g., for
          repair of cervical lacerations)




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Steps for Sharp Curettage (3)

  5. Prepare patient for procedure:
     – Have patient empty her bladder and clean perineum if able to
        do so.
     – Give any prophylactic antibiotics (according to local protocol).
     – Assist into lithotomy position.
  6. Perform a bimanual pelvic examination to assess the size and
     position of the uterus and the condition of the fornices
  7. Administer any parenteral analgesic/anesthesia:
     – Give pethidine IM or IV for pain management.
     – Give oxytocin 10 units IM or ergometrine 0.2 mg before the
        procedure.




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Steps for Sharp Curettage (4)

  8. Prepare the surgical team:
      – Scrub and apply appropriate attire and gloves.
      – Identify roles, including client monitor and circulator.
  9. Drape the patient.
  10. Gently insert a sterile (or high-level disinfected) speculum or
      retractor into the vagina.
  11. Apply antiseptic solution to vagina and cervix (especially the
      os).
  12. Check the cervix for tears or protruding POC:
      – If POC present in the vagina or cervix, remove using a ring
           or sponge forceps.




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Steps for Sharp Curettage (5)

  13. Conduct careful, gentle uterine evacuation:
      – Gently grasp the anterior lip of the cervix with a tenaculum
        or forceps to straighten the uterine cavity.
      – Gently pass a uterine sound through the cervix to assess
        the length/direction of the uterus; compare with previous
        size estimate.
      – Dilate cervix (as needed) to introduce curette:
         Dilatation is needed only in cases of missed abortion or
            when some retained POC have remained in the uterus
            for several days.




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Inserting the Retractor and Holding the Anterior
Lip of the Cervix




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Steps for Sharp Curettage (6)

  • Curette all quadrants of the uterine cavity until there are signs of
    completion.
  • Quickly assess tissue for completeness and consistency with
    diagnosis.




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Curetting the Uterus




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Steps for Sharp Curettage: Caution!

  • Be careful! The uterus is very soft during pregnancy and
    can be easily injured during this procedure.




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Steps for Sharp Curettage—Post-Procedure
Care

  13. (Step 13 continued):
      – Transfer the patient to a comfortable, monitored recovery
        area when she is stable.
      – Give paracetamol 500 mg by mouth as needed.
      – Take vital signs and check for vaginal bleeding every 15
        minutes for 1 hour before discharge from the facility.
      – Encourage the woman to eat, drink and walk about as she
        wishes.
      – Offer other health services, as available and appropriate,
        including tetanus or malaria prophylaxis. When the patient is
        fully awake and alert, inform her of the findings and
        implications for continued treatment.
      – Continue treatment and monitoring as appropriate to her
        condition.

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Steps for Sharp Curettage—Post-Procedure
Counseling

  Provide counseling on the following:
  1. Family planning and the importance of birth spacing or limiting
  2. Discharge instructions
  3. Any other appropriate counseling prior to discharge and follow-
     up care
  4. Date for follow-up appointment




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Post-Procedure Care (2)

  • Provide FP counseling and the method of client’s choice (as
    appropriate) before discharge:
    – If full FP not offered at the site of emergency treatment,
       provide information and referral. Family planning uptake is
       highest when methods are available at the same time and in
       the same location as treatment.
    – Include counseling on return to fertility and birth spacing,
       especially for those clients who desire future pregnancies.




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Post-Procedure Care Integrating Counseling

  • With the client’s permission, include her partner in the
    counseling discussions.
  • Many women want their partners to be informed about their
    condition, treatment, follow-up care and family planning.
  • Men also desire to understand more about emergency
    treatment.




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Post-Procedure Care (3)

  • Discharge uncomplicated cases in 1–2 hours.
  • Post-procedure counseling to include:
    – Watch for signs and symptoms requiring immediate attention:
       • Prolonged cramping
       • Prolonged bleeding
       • Bleeding more than normal menstrual bleeding
       • Severe or increased pain
       • Fever, chills or malaise
       • Fainting




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