Surgery and Healing in the Developing World - Dartmouth-Hitchcock

Outpatient Assessment of the Pregnant Patient
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One (1) packing forceps
One (1) bowl set: one (1) large kidney dish
Two (1) medium kidney dish
One (1) small kidney dish
Three (3) gallipots
The modified set (plus standard trolleys and bowl set etc.)
Perineal towel
Sterilized gauze packs
Sponge holding forceps
Auvard’s weighted speculum
Cervical dilators
Tenaculum
Sharp curette
Additionally for suction curettage –
Suction machine (or regular wall suction)
Suction tube
Suction catheter (e.g., large bore nasogastric tube or endotracheal tube)
Procedure
There is no need to shave the patient. Anaesthesia having been administered, the
patient is placed in the lithotomy position with slight Trendelenburg. The assistant
can monitor and give encouragement and support to the still anxious but otherwise
cooperative patient.
The patient is then cleaned using four pieces of gauze, two savlon and two normal
saline. The initial swabbing is only for the external genitalia, from the mons
pubis, upper one-third of thighs, perineum and anal area. The second savlon gauze
is used for cleansing the vagina and cervical area. The procedure is repeated with
normal saline, which also helps to reduce irritation to or of the genitalia.
The anterior lip of the cervix is firmly grasped with a single-toothed vulsellum,
tenaculum or Allis’ clamp. The author’s personal choice is a single toothed tenaculum
(Fig. 2), the vulsellum (single or multiple toothed) increases risk of traumatic
bleeding. The posterior vagina is retracted by the weighted speculum, which is utilized
to provide good visualization. The cervix is dilated with a series of dilators. In
the case of dilation for evacuation of an incomplete abortion, the cervix should be
dilated in millimeters to a number equal to the number of weeks of uterine size
although this may not be necessary if suction curettage is employed (discussed later).
It is essential that both the internal and external os be dilated with the dilators.
With the cervix on firm upward traction, using the left hand, the thumb can be
used to help exposure by further pressure on the weighted speculum (Fig. 1) If
desirable, and certainly recommended, suction curettage can be performed at this
stage. It is also at this stage that an ergotocic agent such as intravenous ergometrine
can be administered. This has the advantage of inducing contractions, actively reducing
uterine size during the sharp curetting phase. A sharp curette can be inserted
into the uppermost portion of the cavity to ensure evacuation of the cornual areas. It
is essential that a thorough systematic curettage evaluating the entire cavity be carried
out. The curette is inserted to the fundus, and gently, then actively, scraped
along the cavity. Transverse or circular scraping assures better sampling of the entire
cavity, and the surgeon should feel comfortable when a uniform scraping sound is
experienced.
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