Care of Mother and Child At-Risk or

with Problems (Acute and Chronic)-RLE

Module #4 Student Activity Sheet

Name: Class number:

_________________________________________________________________ _______

Section: ____________ Schedule: Date:

________________________________________ ________________

Lesson Title: Manual Vacuum Aspiration and Dilatation Materials:

and Curettage SAS, OB book and pens
Learning Targets:
At the end of the module, students will be able to: References:
1. Discuss the impact of unsafe abortion on maternal
morbidity and mortality. Silbert-Flagg , JoAnne and Pilliteri, Adele
2. List the methods of medical and surgical post abortal (2018) Maternal and Child Health Nursing, 8th
care. Edition. USA: Lippincott Williams and Wilkins
3. Recognize post-abortal care as an essential
component of emergency obstetrical care and that it World Health Organization. (2015).
Pregnancy, childbirth, postpartum and
should be available in every health facility. newborn care: A guide for essential practice
(3rd ed.).

Perinatal Education Programme. (2020)

Maternal Care A Learning Programme for
Professionals

A. LESSON REVIEW/PREVIEW

B. MAIN LESSON
Post-Abortal Care
 Post-abortal care refers to the package of care needed to provide quality services following
spontaneous abortion and unsafe abortion.
 Post-abortal care services should include both medical and preventive care. Essential elements of the
PAC model include: Emergency treatment of incomplete abortion and potentially life-threatening
complications Post-abortal family planning counseling and services Links between post-abortal
emergency services and the reproductive health care system
 Family planning services are an essential component of PAC Services as an Essential Component of
Post-Abortal Care.
 Women who receive PAC without the necessary tools or information needed to prevent subsequent
unwanted pregnancies and abortions may find themselves returning to health centers for similar
services in the future.
 Lack of family planning information and tools leave women trapped in what has been called a harmful
cycle of unwanted pregnancy and unsafe abortion.

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 Care of Mother and Child At-Risk or
with Problems (Acute and Chronic)-RLE
Module #4 Student Activity Sheet

Name: Class number:

_________________________________________________________________ _______

Section: ____________ Schedule: Date:

________________________________________ ________________

 Research shows that reaching women at this critical stage helps to increase contraceptive use
significantly, leading to fewer repeat and possibly unsafe abortions.

Clinical Features for Diagnosis of Abortion

The following table provides a summary of the main signs and symptoms to aid prompt differential diagnosis of
an abortion.

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 Care of Mother and Child At-Risk or
with Problems (Acute and Chronic)-RLE
Module #4 Student Activity Sheet

Name: Class number:

_________________________________________________________________ _______

Section: ____________ Schedule: Date:

________________________________________ ________________

Management

General management
Every health care system must provide some level of PAC, whether at the district and/or community level. The
services provided will depend on the type of facility and its capacities.
Suggested post-abortal care services by level of health care facility and staff

This document is the property of PHINMA EDUCATION

 Care of Mother and Child At-Risk or
with Problems (Acute and Chronic)-RLE
Module #4 Student Activity Sheet

Name: Class number:

_________________________________________________________________ _______

Section: ____________ Schedule: Date:

________________________________________ ________________

This document is the property of PHINMA EDUCATION

 Care of Mother and Child At-Risk or
with Problems (Acute and Chronic)-RLE
Module #4 Student Activity Sheet

Name: Class number:

_________________________________________________________________ _______

Section: ____________ Schedule: Date:

________________________________________ ________________

Management of Spontaneous Abortion

Threatened abortion Inevitable abortion
1. Medical treatment is usually not necessary. 1. If pregnancy is less than 16 weeks: Plan for
MVA of uterine contents.
2. The woman is advised to avoid strenuous
activity and sexual intercourse, but bed rest is 2. If evacuation is not immediately possible:
not necessary. Give ergometrine 0.2% mg IM (repeated
after 15 minutes if necessary) OR
3. If bleeding stops: Follow-up in antenatal clinic. misoprostol 400 µg by mouth (repeated once
Reassess if bleeding recurs. after 4 hours if necessary).

4. If bleeding persists: Assess for fetal viability 3. Arrange for evacuation of uterus as soon a
(pregnancy test or ultrasound) or ectopic possible.
pregnancy (ultrasound).
4. If pregnancy is greater than 16 weeks:
5. Persistent bleeding, particularly in the
presence of a uterus larger than expected, Await spontaneous expulsion of product of
may indicate twins or molar pregnancy. conception and then evacuate the uterus to
remove any remaining product of
6. Do not give hormones because they will not conception.
prevent miscarriage
If necessary, infuse oxytocin 40 units in 1L
IV fluids (normal saline or Ringer’s lactate at
40 drops per minute) to help achieve
expulsion of product of conception.

5. Ensure follow-up of the woman after

treatment.
Incomplete abortion Complete abortion
1. If bleeding is slight to moderate and 1. Evacuation of the uterus is NOT necessary.
pregnancy is less than 16 weeks: Use fingers
or ring (or sponge) forceps to remove POC 2. Observe for heavy bleeding.
protruding through the cervix.
3. Ensure follow-up of the woman after the
2. If bleeding is heavy and pregnancy is less treatment.
than 16 weeks: Evacuate the uterus: MVA is
the preferred method of evacuation.

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 Care of Mother and Child At-Risk or
with Problems (Acute and Chronic)-RLE
Module #4 Student Activity Sheet

Name: Class number:

_________________________________________________________________ _______

Section: ____________ Schedule: Date:

________________________________________ ________________

Evacuation by sharp curettage should only be

done if MVA is not available.

3. If evacuation is not immediately possible: Give

ergometrine 0.2 mg IM (repeated after 15
minutes if necessary) or misoprostol 400 µg
orally (repeated once after 4 hours if
necessary).

4. If pregnancy is greater than 16 weeks: Infuse

oxytocin 40 units in 1 L IV fluids (normal saline
or Ringer’s lactate) at 40 drops per minute
until expulsion of POC occurs.

5. If necessary, give misoprostol 200 µg

vaginally every 4 hours until expulsion, but do
not administer more than 800 µg.

6. Evacuate any remaining POC from the uterus.

7. Ensure follow-up of the woman after the

treatment.
Management of Induced Abortion Performed in Unsafe Environment
Emergency treatment for post-abortal complications 5. Stabilization of emergency conditions and
includes: treatment of any complications—
1. An initial assessment to confirm the presence complications present before treatment and
of abortion complications. those occurring during or after the treatment
procedure.
2. Supporting the woman while assessing her
condition and explaining the treatment plan. 6. Assessment of the signs and symptoms of
septic abortion, such as:
3. Medical evaluation (brief history, limited fever >38.5°C 48 hours following abortion,
physical and pelvic examinations, history of chills or sweats,
excessive bleeding, easy bruising or known foul-smelling vaginal discharge,
blood disorder that could be due to lower abdominal tenderness and/or pain,
coagulopathy, and risk for excessive mucous from the cervix,
bleeding). prolonged bleeding (for more than 8hrs),
general discomfort,
4. Prompt referral and transfer if the woman flu-like symptoms,
requires treatment beyond the capacity of the hemodynamic and

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 Care of Mother and Child At-Risk or
with Problems (Acute and Chronic)-RLE
Module #4 Student Activity Sheet

Name: Class number:

_________________________________________________________________ _______

Section: ____________ Schedule: Date:

________________________________________ ________________

facility where she is seen. acid-based equilibrium changes.

7. As the condition worsens, the patient is less

alert with tachycardia, hypotension,
peripheries pale and clammy, nausea,
vomiting, and diarrhea. If a septic abortion
with hypotension out of proportion of the
blood loss, septic shock should be
suspected

8. Uterine evacuation to remove retained

product of conception.
Post-abortal Follow-up
Women who have had a spontaneous abortion: Women who have had an unsafe abortion:
 Must be supported psychologically.  Must be counselled on family planning
methods that can be started immediately
 Should be informed that spontaneous abortion (within 7 days).
is common and occurs in at least 15% (1 in
every 7) of clinically recognized pregnancies.  Family Planning Services as an Essential
Part of Post-Abortal Care.
 Must be reassured that their chances for a
subsequent successful pregnancy are good  Must be referred to any other reproductive
unless there has been sepsis or a cause of health services that may be needed:
abortion that has been identified as having an RhoGAM, tetanus prophylaxis or tetanus
adverse effect on future pregnancies (this is booster, treatment for sexually transmitted
rare). infections, cervical cancer screening, etc.

 Should be encouraged to delay the next  Must be invited to express their feelings and
pregnancy until they are completely fears related to the circumstances of the
recovered. unwanted pregnancy, such as rape, failed
contraception, lack of access to
contraception, etc.

Surgical and Medical Methods for the Management of Spontaneous and Unsafe Abortion, and
Approved by International Guidelines
 Medical methods, also known as non-surgical methods, make use of pharmacological drugs to treat
conditions of post abortion.

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 Care of Mother and Child At-Risk or
with Problems (Acute and Chronic)-RLE
Module #4 Student Activity Sheet

Name: Class number:

_________________________________________________________________ _______

Section: ____________ Schedule: Date:

________________________________________ ________________

 Surgical methods make use of transcervical procedures, such MVA, dilatation and curettage (D&C),
and dilatation and evacuation (D&E). Medical and surgical methods are safe, and can save the life of
the woman if used properly and effectively. In countries where abortion services are legal, they are
recognized as the safest approach to medical and surgical abortion care. The Society of Obstetricians
and Gynaecologists of Canada, the American College of Obstetricians and Gynecologists, the Royal
College of Obstetricians and Gynaecologists (UK), and WHO have all adopted guidelines for abortion
care.

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 Care of Mother and Child At-Risk or
with Problems (Acute and Chronic)-RLE
Module #4 Student Activity Sheet

Name: Class number:

_________________________________________________________________ _______

Section: ____________ Schedule: Date:

________________________________________ ________________

EMERGENCY INTERVENTIONS FOR BLEEDING IN PREGNANCY

INTERVENTION RATIONALE
1. Alert healthcare team of emergency Provides maximum coordination of care
situation.
2. Place woman flat in bed on her side. Maintains optimal placental and renal function
3. Begin intravenous fluid such as Ringer’s lactate Replaces intravascular fluid volume; intravenous line
with a 16- or 18-gauge Angiocath. is established if blood replacement will be needed
4. Administer oxygen as necessary at 6–10 L/min by Provides adequate fetal oxygenation despite lowered
face mask. maternal circulating blood volume
5. Monitor uterine contractions and fetal heart rate by Assesses whether labor is present and fetal status;
external monitor. external system avoids cervical trauma
6. Omit vaginal examination. Prevents tearing of placenta if placenta previa is
cause of bleeding
7. Withhold oral fluid. Anticipates need for emergency surgery
8. Order type and cross-match of 2 units of whole Allows for restoring circulating maternal blood
blood. volume if needed
9. Measure intake and output. Enables assessment of renal function (will decrease
to under 30 ml/hr with massive circulating volume
loss)
10. Assess vital signs (pulse, respirations, and blood Provides objective evidence of amount of bleeding;
pressure every 15 min; apply pulse oximeter and saturating a sanitary pad in less than 1 hr is heavy
automatic blood pressure cuff as necessary). blood loss; tissue may be abnormal trophoblast
tissue
11. Assist with placement of central venous pressure Provides more accurate data on maternal
or pulmonary artery catheter and blood hemodynamic state
determinations.
12. Measure maternal blood loss by weighing Provides objective evidence of amount of bleeding;
perineal pads; save any tissue passed. saturating a sanitary pad in less than 1 hr is heavy
blood loss; tissue may 1170 be abnormal trophoblast
tissue
13. Assist with ultrasound examination. Supplies information on placental and fetal well-
being
14. Maintain a positive attitude about fetal outcome. Supports mother–child bonding
15. Support woman’s self-esteem; provide emotional Assists problem solving, which is lessened by poor
support to woman and her support person. self-esteem.

Medical methods of treating spontaneous and unsafe abortion

Procedure for Manual Vacuum Aspiration.

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 Care of Mother and Child At-Risk or
with Problems (Acute and Chronic)-RLE
Module #4 Student Activity Sheet

Name: Class number:

_________________________________________________________________ _______

Section: ____________ Schedule: Date:

________________________________________ ________________

 Surgical methods of post abortion to evacuate the uterus

Surgical methods of post abortion include:

 MVA
 Dilatation and curettage
 Dilatation and evacuation

After any surgical method, immediate examination of POC is important to exclude the possibility of ectopic
pregnancy, verify any appearance suggestive of molar pregnancy, and to consider incomplete abortion.
1. Manual vacuum aspiration (MVA): Vacuum aspiration is the most preferred, appropriate, and cost-
effective procedure in low-resource settings. It is the preferred surgical technique up to 16 weeks. Its
high efficacy has been well established in several randomized controlled trials. Vacuum aspiration has
replaced D&C in routine use in most industrialized countries and in many other countries.

 With MVA, the vacuum is created using a hand-held, hand-activated, plastic 60 ml syringe. It takes from
3 to 10 minutes to complete, and can be performed on an outpatient basis, using analgesics and/or
local anesthesia.

 Though rare, complications with vacuum aspiration can include pelvic infection, excessive bleeding,
cervical injury, incomplete evacuation, uterine perforation, anesthesia complications, and ongoing
pregnancy.

 Abdominal cramping or pain and menstrual-like bleeding are normal side effects with any abortion
procedure. Precautions for performing manual vacuum aspiration

 In the course of the initial assessment, conditions may be discovered that indicate delaying the MVA
procedure and initiating other treatment(s) before beginning the MVA, or the need to use a different
technique for removing POC.

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 Care of Mother and Child At-Risk or
with Problems (Acute and Chronic)-RLE
Module #4 Student Activity Sheet

Name: Class number:

_________________________________________________________________ _______

Section: ____________ Schedule: Date:

________________________________________ ________________

Complications with Collaborative Management

2. Dilatation and curettage: Also known as sharp curettage, D&C involves dilating the cervix with
mechanical dilators or pharmacological agents and using sharp metal curettes to scrape the walls of
the uterus. It is less safe than vacuum aspiration and considerably more painful for women.

3. Dilatation and evacuation: D&E is used from about 12 completed weeks of pregnancy. It is the safest
and most effective surgical technique for later abortion where skilled, experienced providers are
available. D&E requires preparing the cervix with a prostaglandin, dilating the cervix, and evacuating
the uterus using electric vacuum aspiration with 14 mm to 16 mm diameter cannula and forceps.

This document is the property of PHINMA EDUCATION

 Care of Mother and Child At-Risk or
with Problems (Acute and Chronic)-RLE
Module #4 Student Activity Sheet

Name: Class number:

_________________________________________________________________ _______

Section: ____________ Schedule: Date:

________________________________________ ________________

Check for Understanding

You will answer these questions below and it will be recorded as your quiz.

Essay (5 points each)

1. How should you decide whether a patient can be managed locally or whether she should be
transferred? Clinics and level 1 hospitals which do not have blood available must refer all patients
with an antepartum hemorrhage.

2. When you refer a patient, what precautions should you take to ensure the safety of the patient in
transit?

C. LESSON WRAP-UP
AL Strategy: Minute Paper
1. Please prepare a question or write a question in an index cards or half-sheets of paper to write
feedback to the following questions:
a. What was the most useful or the most meaningful thing you have learned this session?
b. What question(s) do you have as we end this session?

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