Simulation

First Trimester Uterine Aspiration

Simulation

- A ripe medium or large papaya (Note: cantaloupe can also be substituted)
  - Create a cervical os in each papaya by poking a hole in the stem of the papaya with a uterine sound
- A large plastic or paper cup to have papaya sit in (optional)
- A hemipelvis to place papaya in to mimic a uterus in a pelvis (optional)
- A standardized patient (SP) can be used for the counseling portion of the simulation
The room should be set up as similarly as an office patient room or procedure room if you are going to run through the entire scenario of speaking/counseling the patient and then performing the task. If only the task is going to be done, then the set up would not be as significant.

On a tray table, the following items should be set up:
- Single-toothed tenaculum
- Betadine swabs
- Speculum
- Needle extender
- Ring forceps
  - Cannula
  - Rigid or flexible
- Dilators
  - Tapered are preferred
  - Denniston or Pratt
- Silver nitrate sticks
- Papaya on a table lined with paper or chux
- Papaya sitting in a large paper/plastic cup (optional)
- Papaya sitting in a hemipelvis (optional)
- Chair or rolling stool for learner to sit on
- Chair for SP to sit (if using a SP for counseling)
Optional Equipment
- Sharp curettes
Personnel Needed
- Staff member to set up the papayas and equipment
- Standardized Patient (SP) if so desired

Answers to Common Questions

Remember that this is a simulation. Nothing can be as exact as real life, but this is a close approximation.
Reiterate that what is important is the learner going through the steps of the procedure from start to finish, so they are more familiar with them when they actually do the procedure in the office.

Common Pitfalls to Monitor

Getting a green papaya may make the aspiration more difficult. Try to make sure that the papayas are ripe.

Assemble all of the equipment as described above
Begin counseling the patient on all of the risks, benefits, and alternatives to procedure (if using a SP, if not proceed to step 4)
Conduct a timeout
Bimanual exam for size/position of uterus (if using a hemipelvis with papaya)
Insert speculum and clean cervix with betadine (if using hemipelvis with papaya)
Perform a paracervical block
1. Using 0.5 or 1% lidocaine- with or without a vasoconstrictor
2. Continuous injection in and out to 3cm at 2, 4, 8, and 10 o’clock at the cervicovaginal junction
Place tenaculum on anterior lip
1. Close ratchets slowly to lessen pain
2. Exert traction on cervix for dilation
Prepare the MVA syringe
1. Attach the curette
2. Close the valve
3. Pull back the plunger
Select cannula
1. Gestational age or gestational age+1mm
Insert cannula and perform curettage a. Release valves once inserted
Once an adequate specimen is obtained, remove the tenaculum
1. You would inspect the tenaculum site for bleeding in a live patient
2. Apply hemostatic treatment if needed (i.e., silver nitrate sticks)
Remove speculum
Examine tissue to ensure gestational sac is present
1. Strain and rinse the tissue
2. Place tissue in a clear container
3. Recommended: Backlight to inspect tissue

The resident will be able to identify indications and contraindications for MVA in the office setting and be able to counsel the patient appropriately
The resident will be able to identify the equipment and supplies necessary for an in office MVA
The resident will be able to demonstrate in a simulated environment the steps of an in office manual vacuum aspiration