9.1 Precautions required for intrauterine procedures

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    There are 2 types of intrauterine procedures:
    – Manual: manual removal of the placenta, uterine exploration, and digital curettage;
    – Instrumental: manual vacuum aspiration (MVA), instrumental curettage, and embryotomy.

    9.1.1 Precautions common to all intrauterine procedures

    Bladder emptying

    This facilitates the procedure and reduces the risk of bladder injury.
    – Have the patient urinate on her own.
    – Insert a sterile urinary catheter only if the patient does not urinate on her own.

    Asepsis

    – Cleanse the vulva and perineum with the povidone iodine scrub (or, if not available, ordinary soap). Rinse and dry. Then, swab the vulva and perineum with 10% povidone iodine solution.
    – Use sterile drapes, sterile compresses and sterile gloves (sterile gynaecological gloves, with long cuffs, for manual procedures).

    Anaesthesia

    All procedures should be performed under anaesthesia. A procedure may be done without anaesthesia on two conditions: it is a life-threatening emergency (e.g. postpartum haemorrhage due to retained placenta) and anaesthesia cannot be performed immediately.
    For manual vacuum aspiration, a combination of premedication and local anaesthetic (paracervical block) provides adequate anaesthesia.

    Protection of personnel

    All intrauterine procedures expose the practitioner to the risk of blood-borne pathogen infection. Personal protective equipment is essential (gloves, gown, rubber or plastic apron, mask, protective eyewear).

    9.1.2 Specific precautions for manual procedures

    For all manual intrauterine procedures, add:

    – Antibiotic prophylaxis before the procedure:
    cefazolin or ampicillin slow IV a Citation a. For patients with a history of immediate hypersensitivity reaction to penicillin (urticaria, respiratory problems or oedema): clindamycin IV 900 mg single dose + gentamicin IV 5 mg/kg single dose. : 2 g single dose
    AND
    – A uterotonic agent (right after the procedure) to improve uterine contraction:
    oxytocin IM or slow IV: 5 to 10 IU single dose 

    Footnotes
    • (a)For patients with a history of immediate hypersensitivity reaction to penicillin (urticaria, respiratory problems or oedema): clindamycin IV 900 mg single dose + gentamicin IV 5 mg/kg single dose.