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    Female reproductive system image, stylized This Uterine Aspiration course provides learners with the foundational knowledge required to provide uterine aspiration care for incomplete miscarriage with retained products of conception, and for abortions in the first trimester of pregnancy. The course addresses the core competencies outlined in the World Health Organization (WHO) document “Sexual and reproductive health: Core competencies in primary care”. All components of this training (like all NextGenU.org trainings) are free, including registration, learning, testing, and a certificate of completion.

    This course is designed for healthcare providers with at least a foundational knowledge of physiology and pharmacology, clinical skills (history taking, physical exam), and basic ultrasound.  The course may be appropriate for advanced medical students, medical residents, or primary care-level providers including advanced practice clinicians. Components of the course may also be suitable for auxiliary staff such as counselors, medical assistants, and nurses.

    There are seven lessons to complete through online study and peer and mentored activities. These modules introduce counseling and informed consent; assessing eligibility for aspiration abortion; pre-procedure medication and pain management; aspiration procedure; post-procedure care; complications; and logistics of providing aspiration abortion. At the end of this course, learners should have the knowledge needed to discuss abortion care options and informed consent; complete a pre-abortion evaluation and describe the eligibility criteria for aspiration abortion; identify steps of the uterine aspiration procedure; perform a first-trimester aspiration abortion within a simulation environment; describe the components of post-abortion care; and describe the  steps for evaluation and management of abortion complications.

    Practice quizzes are found in each module, and at the end of the course you’ll take a final exam and have a chance to assess this training. We will provide you with the results of your final exam, peer activities, and other assessments. We can report your testing information and share your work with anyone (school, employer, etc.) you request. We hope this is a wonderful learning experience for you and that your assessments will teach us how we can make it even better.
     
    Like all NextGenU.org courses, this course is competency-based, using competencies from the World Health Organization (WHO) and learning resources from world-class academic and governmental organizations such as the University of California, San Francisco, Bixby Center for Global Reproductive Health, and the World Health Organization. The course developers include Sara Baird MD and Amelia Plant MPH, and the advisory committee includes Francine Coeytaux MPH, Marji Gold MD MPH, Gwewasang Martin, Wendy Norman MD MPH, and Linda Prine MD.  Our co-sponsoring organizations include the Clinical Training Center for Family Planning in Cameroon (CTC4FP), Plan C, the Reproductive Health Access Project (RHAP), TEACH, and The Center for Reproductive Health Education In Family Medicine (RHEDI).  Some content from this course has been adapted from the Ipas courses "First Trimester Abortion with Mifepristone and Misoprostol” and/or “Uterine Evacuation with Ipas MVA Plus® ” (accessed December 2017). The original course material can be found at the IpasUniversity online learning portal at www.ipasu.org. For more information about Ipas, go to  www.ipas.org.

    When you're ready to begin the course, please start by taking the survey icon pre-course survey and pre-course test below.
  • Checklist icon

    Before you begin the course, you must complete two short tasks: (1) the Pre-Course Survey, and (2) the Pre-Course Test. Please DO NOT proceed with the course unless you have filled out both. These allow us to access various aspects of the course itself and are MANDATORY to receive your certificate upon completion of the course. If you do not wish to receive a certificate, but are a qualified health provider who wishes to learn this information, please feel free to learn from the materials without registering or completing the pre-test. Thank you very much; we hope you find the course useful. 

  • Abortion is common. Globally, about 25% of all pregnancies ended in abortion between 2010 and 2014. Preventing unplanned births by the use of contraceptives and safe abortion has benefits at the individual, family, and societal levels. Women who are able to choose when to have children are better able to chart the courses of their own lives. They are more likely to complete higher levels of education, be more active in the workforce, and contribute more to a country’s economy (Reher, 2011). Limiting family sizes decreases household poverty, as more resources are available to educate, clothe, house, and feed existing family members (UNFPA, 2010).

    At the country level, as the number of children per household falls, the number of people in the workforce rises. This results in a favorable economic situation that allows countries to develop (Bloom, Canning, & Sevilla, 2003). Historically, no country has successfully developed without a corresponding drop in fertility.

    Providing access to contraception goes a long way, but unplanned pregnancies cannot be eliminated altogether. A woman may experience an unplanned pregnancy for a number of reasons, including lapse in access, contraceptive failure, reproductive coercion or sexual assault, or diagnosis of abnormal pregnancy. Safe abortion is essential to women’s emotional and physical health, family-level economic opportunities, and societal development.

    Although legal abortion is safe and effective, complications from unsafe abortion are common in regions where abortion is illegal or highly restricted, and is a leading global cause of death for women aged 1519 (Guttmacher). Increasing access to abortion and reproductive health information has even been shown to lower abortion rates (UNFPA, 2010). But even in settings where abortion is legal, restrictions often limit women’s access to care. The training of providers is an essential step to destigmatizing abortion care, and expanding geographic access to care.

    Click here to start this module

    5 URLs
  • Medical clinical concepts

    The course contains the following lessons:      

    1. Counseling and Informed Consent
    2. Assessing Eligibility for Aspiration Abortion
    3. Pre-procedure Medications and Pain Management
    4. Aspiration Procedure
    5. Post-procedure Care    
    6. Complications
    7. Logistics of Providing Aspiration Abortion

    Click here for the brief module introduction

  • Uterine evacuation using the aspiration technique can be done for a variety of indications, including for termination of an undesired pregnancy, management of a miscarriage or abnormal pregnancy, uterine sampling, and menstrual regulation. 

    This course will focus on manual vacuum aspiration (MVA) for the purpose of termination of pregnancy, although much of the content is applicable to the other indications.

    The World Health Organization recommends that uterine evacuation be performed with vacuum aspiration (usually manual vacuum aspiration) whenever possible, instead of dilation and sharp curettage (D&C).  The use of sharp curettage is not routinely recommended and will not be covered in this course.

    Terminology

    The term ‘aspiration abortion’ is used throughout this course to refer to uterine evaluation using suction technique. Other terms such as ‘surgical abortion,’ ‘in-clinic abortion,’ ‘uterine aspiration,’ ‘uterine evacuation,’ and ‘vacuum aspiration’ can all also be used to describe an abortion using suction technique.

  • National Abortion Federation: A Values Clarification Guide for Health Professionals

    Who can provide abortions?

    Abortion providers may have a variety of background trainings. For more information about who can provide abortion services, read the documents listed below from the World Health Organization and the National Abortion Federation

    Values Clarification

    Before beginning this course, take a moment to reflect on your own values as a provider. Many people have social, religious, cultural, and personal influences on their practice as an abortion provider.  These influences can consciously or subconsciously affect our patient interactions during counseling and care.

    Consider completing an individual values clarification workbook such as the one available through the U.S.-based National Abortion Federation, "A Values Clarification Guide for Health Care Professionals."

    It is also important to consider the values of your staff, colleagues, and patients before implementing abortion care. Resources for group values clarification workshops will be presented at the end of this course.

    Click here to start this module

    3 URLs

  • Learning objectives

    • Use patient-centered language to discuss early pregnancy options
    • Review early abortion options with patients
    • Describe steps of informed consent for women seeking aspiration abortion
    • Explain the aspiration abortion process to patients and provide aftercare instructions

    Click here for the brief module introduction


  • Key Points
    • Providers should focus on good communication throughout the visit, both verbally, non-verbally, and with clear written materials.
    • Good communication includes using open-ended questions, listening actively, and understanding that the patient knows what is right for her.
    • Confidentiality and limits of confidentiality should be reviewed early in the visit with the patient so she understands her rights to privacy.
    • Minors (usually defined as under 18 years of age) may not be able to consent to abortion care without a parent or guardian present.
     

    Learning Objectives

        • Describe terms and phrases that can be used to nurture a non-judgmental and patient-centered environment
        • Describe how non-verbal communication can be used during an abortion visit
        • Use patient-centered language to discuss early pregnancy options
        • Describe the concept of confidentiality and how it may apply to the patient

    We will first review overall tips for effective and empathetic communication with patients.  The readings below include examples of verbal and nonverbal communication that can be utilized throughout a women’s abortion visit.


    Click here to start this module

    4 URLs, 1 Assignment

  • Key Points
    • Women should receive counseling about aspiration versus medication abortion based on their individual factors.
    • Many women who choose aspiration abortion prefer it because it commonly causes less bleeding than with the medication abortion, is slightly more effective, can be done later into the pregnancy, and faster (she can leave the clinic knowing she is no longer pregnant).

     

    Learning Objectives

    • Explain to a patient or colleague the risks and benefits of manual vacuum aspiration versus medication abortion

    There are two main types of abortion, medication abortion (also called "medical abortion" or "pill abortion") and aspiration abortion (most commonly, manual vacuum aspiration, also called "surgical abortion" or "in-clinic abortion").

    A woman may have many reasons for choosing one type of abortion over another.  These may include her prior experience, chronic medical conditions, and clinic availability. This lesson reviews some of the differences between medication and aspiration abortion and how to discuss these differences with patients to develop the right plan of care.


    Click here to start this module

    3 URLs

  • Key Points 
    • During informed consent, the provider should discuss risks and safety information with the patient, and confirm a patient’s understanding of the process of aspiration abortion.
    • Review any legal restrictions that may apply to your clinical practice about informed consent, such as required counseling content or mandatory forms.
     

    Learning Objectives

    • Describe the importance of clear communication with patients
    • Review the key components of informed consent for aspiration abortion
    • Identify sample resources that can be utilized to develop your own informed consent document for clinical practice

    Click here to start this module

    1 URL, 1 Forum

  • Key Points 
    • By the end of the informed consent process, women should understand what the rest of their clinic visits will entail, how the aspiration abortion works, how to take care of themselves after the abortion, and any warning signs to re-contact the clinic.
    • Counseling should be tailored to each individual patient; ask the women how much detail they want to know about the abortion procedure before describing it.

     

    This lesson will review how to talk to women about what to expect during and after the aspiration procedure. Note that the material discussed here may come up at different times during the counseling process.  Some women may ask for more details when choosing between aspiration and medication abortion.  Others will choose to have an aspiration abortion, and only need more detail later in the informed consent process.

    This lesson will review what additional information should be shared with the patient before an aspiration abortion.

     Learning Objectives

    • Learn how to describe the aspiration abortion procedure to patients
    • Review aftercare instructions, including warning signs, with patients

    Click here to start this module

    5 URLs, 1 Forum

  • Key Points

    Lesson 1.1

    • Providers should focus on good communication throughout the visit, both verbally, non-verbally, and with clear written materials.
    • Good communication includes using open-ended questions, listening actively, and understanding that the patient knows what is right for her.
    • Confidentiality and limits of confidentiality should be reviewed early in the visit with the patient so she understands her rights to privacy.
    • Minors (usually defined as under 18 years of age) may not be able to consent to abortion care without a parent or guardian present.

     Lesson 1.2

    • Women should receive counseling about aspiration versus medication abortion based on their individual factors.
    • Many women who choose aspiration abortion prefer it because it commonly causes less bleeding than with the medication abortion, is slightly more effective, can be done later into the pregnancy, and faster (she can leave the clinic knowing she is no longer pregnant).

     Lesson 1.3

    • During informed consent, the provider should discuss risks and safety information with the patient, and confirm a patient’s understanding of the process of aspiration abortion.
    • Review any legal restrictions that may apply to your clinical practice about informed consent, such as required counseling content or mandatory forms.

    Lesson 1.4

    • By the end of the informed consent process, women should understand what the rest of their clinic visits will entail, how the aspiration abortion works, how to take care of themselves after the abortion, and any warning signs to re-contact the clinic.
    • Counseling should be tailored to each individual patient; ask the women how much detail they want to know about the abortion procedure before describing it.


  • Learning objectives


    At the end of this lesson, learners will be able to:

    • Identify the general eligibility criteria for aspiration abortion, and be able to find the eligibility criteria for aspiration abortion in their country
    • Describe how to diagnose and date a pregnancy
    • Explain how to screen for ectopic pregnancy
    • Describe the contraindications to aspiration abortion
    • Identify the recommended laboratory testing prior to aspiration abortion

    This lesson will provide information on assessing a woman’s eligibility to obtain an aspiration abortion.

    Click here for the brief module introduction


  • Key Points
    • A history and physical should focus on obtaining information about gestational age, identifying contraindications and identifying risk factors for complications.
    • Most labs are not a required part of evaluation before abortion. Lab testing that may be done prior to aspiration abortion includes hemoglobin and Rh testing; these tests are considered mandatory in some settings (in the U.S., for example) but may be considered optional depending on the clinical setting and patient factors.

     

    Learning Objectives

    • Describe the components of a pertinent history and physical exam for patients seeking abortion

    The first step to assessing a woman’s eligibility for an abortion is obtaining information about her medical history, focusing on information that may affect her eligibility.


    Click here to start this module

    2 URLs

  • Key Points
    • Last menstrual period (LMP) in conjunction with a bimanual exam can reliably estimate gestational age in most patients.
    • When the bimanual exam findings do not correlate to the expected gestational age (by LMP) it is important to consider inaccurate dating, as well as alternative diagnoses. Ultrasound should be considered in this setting.
    • In some settings where ultrasound is easily available, ultrasound is considered the standard of care.

     

    Learning Objectives

    • Describe different methods of diagnosing pregnancy
    • Describe the benefits and limitations of using the last menstrual period (LMP), bimanual exam or ultrasound for early pregnancy dating
    • Assess gestational age and confirm pregnancy is in the first trimester
    • Describe the expected human chorionic gonadotrophin (hCG) and ultrasound findings for normal intrauterine pregnancies at varying gestational ages.

    Click here to start this module

    2 URLs

  • Key Points
    • Patients should be screened for ectopic pregnancy by history and physical exam, and additional testing including ultrasound should be done if indicated.
    • Medication or aspiration abortion will NOT treat ectopic pregnancy. All patients with suspected or confirmed ectopic should be emergently referred to an experienced provider where appropriate evaluate and treatment can be done.
    • Aspiration abortion can be done as a diagnostic test when a woman has a pregnancy of unknown location. To exclude ectopic, quantitative hCG levels must be followed, and should drop rapidly and appropriately based on the testing interval.

     

    Learning Objectives

    • Describe the history and physical exam findings that suggest ectopic pregnancy

    Click here to start this module

    1 URL

  • Key Points
    • There are no absolute contraindications to aspiration abortion.
    • Special consideration should be given to patients with certain conditions, such as known uterine abnormalities that may make the procedure difficult. Other conditions may prompt referral for aspiration abortion in a higher level of care, for example severe anemia. Decision to proceed with the aspiration abortion will depend on the clinical setting and available resources.

     

     Learning Objective:

    • Describe the relative and absolute contraindications for medication abortion

    Click here to start this module

    1 URL

  • Key Point
    • While there are no absolute lab requirements prior to abortion, Hemoglobin and Rh testing (when Rh immunoglobulin is available) should be done. Offer screening for sexually transmitted infection (chlamydia, gonorrhea, HIV).

     

    Learning Objectives

    • Describe the recommended laboratory testing prior to abortion

    The required reading here is the SAME as in the medication abortion course. If you have taken the medication abortion course, you are not required to repeat this reading.  Always check your local standard of care, which may be different for medication versus aspiration abortion. 

    Recommendations for lab testing may vary by geographical standard of care. Medically speaking, there are no absolutely required lab tests prior to abortion (medication or aspiration). However, lab tests are frequently done and primarily focus on public health (screening for sexually transmitted infection) and/or screening for contraindications (hemoglobin). Abortions should not be delayed beyond the same day while waiting for screening lab results. This does not apply to labs that are done for diagnostic purposes, and as always is at the discretion of the provider.

    Click here to start this module

    2 URLs

  • Key Points

    Lesson 2.1

    • A history and physical should focus on obtaining information about gestational age, identifying contraindications and identifying risk factors for complications.
    • Most labs are not a required part of evaluation before abortion.  Lab testing that may be done prior to aspiration abortion includes hemoglobin and Rh testing; these tests are considered mandatory in some settings (in the U.S., for example) but may be considered optional depending on the clinical setting and patient factors.


    Lesson 2.2

    • Last menstrual period (LMP) in conjunction with a bimanual exam can reliably estimate gestational age in most patients.
    • When the bimanual exam findings do not correlate to the expected gestational age (by LMP) it is important to consider inaccurate dating, as well as alternative diagnoses.  Ultrasound should be considered in this setting.
    • In some settings where ultrasound is easily available, ultrasound is considered the standard of care.

     
    Lesson 2.3

    • Patients should be screened for ectopic pregnancy by history and physical exam, and additional testing including ultrasound should be done if indicated.
    • Medication or aspiration abortion will NOT treat ectopic pregnancy.  All patients with suspected or confirmed ectopic should be emergently referred to an experienced provider where appropriate evaluate and treatment can be done.
    • Aspiration abortion can be done as a diagnostic test when a woman has a pregnancy of unknown location. To exclude ectopic, quantitative hCG levels must be followed, and should drop rapidly and appropriately based on the testing interval.


    Lesson 2.4

    • There are no absolute contraindications to aspiration abortion.
    • Special consideration should be given to patients with certain conditions, such as known uterine abnormalities that may make the procedure difficult. Other conditions may prompt referral for aspiration abortion in a higher level of care, for example severe anemia. Decision to proceed with the aspiration abortion will depend on the clinical setting and available resources.


    Lesson 2.5

    • While there are no absolute lab requirements prior to abortion, Hemoglobin and Rh testing (when Rh immunoglobulin is available) should be done. Offer screening for sexually transmitted infection (chlamydia, gonorrhea, HIV).


  • Learning objectives

    At the end of this lesson, learners will be able to:

    • Describe the indications for antibiotics during aspiration abortion
    • Describe the indications for use of agents for cervical ripening
    • Describe the evidence for Rh immunoglobulin during aspiration abortion
    • Describe the methods for managing pain during aspiration abortion

    This lesson will provide information on how to manage pain and medications before and during an aspiration abortion.

    Click here for the brief module introduction


  • Key Points
    • Antibiotic prophylaxis is recommended prior to aspiration abortion, but unavailability of antibiotics should not limit access to abortion.
    • If infection is suspected based on history or physical, treatment doses should target the suspected infection using regional guidelines for antibiotic choice, and if possible should be administered one hour prior to the procedure.
    • Women should be offered appropriate screening for sexually transmitted infections when they present for abortion, but testing is not a requirement.


    Learning Objectives

    • Describe the indications for prophylactic antibiotics during aspiration abortion
    • List at least three antibiotic regimens which may be selected for prophylaxis before aspiration abortion
    • Describe scenarios in which additional antibiotics may be given

    Click here to start this module

    2 URLs

  • Key Points
    • There is no data that Rh alloimmunization occurs during first trimester abortion or miscarriage.
    • Rh testing is routinely done and is the standard of care in many settings where anti-D immunoglobulin is readily available for patients.
    • Rh testing and anti-D immunoglobulin is not a requirement for aspiration abortion and is not done in many settings, especially where anti-D immunoglobulin is not readily available.

     

    The required reading here is the SAME as in the medication abortion course. If you have taken the medication abortion course, you are not required to repeat this reading.  However, please note that your local standard of care may be different for medication versus aspiration abortion – please complete the activity below including the relevant information for aspiration abortion. 

    Learning Objectives

    • Describe the evidence for anti-D immunoglobulin use during first trimester abortion
    • Identify the local regulations and standard of care regarding use of Rh testing and anti-D immunoglobulin in your practice area

    Click here to start this module

    1 Forum

  • Key Points
    • Contraception should be offered to women on the same day as the abortion, as ovulation may occur soon after the abortion is complete and before the next menses.
    • Intrauterine devices are safe to insert immediately post-abortion.

     

    Learning Objectives

    • Describe the recommendations for initiating contraception after aspiration abortion
    • Counsel women about contraceptive options after abortion

    Click here to start this module

    4 URLs

  • Key Points
    • Cervical preparation is rarely indicated for women under 12 weeks gestation. Most providers start using cervical preparation between 12 and 14 weeks gestation.
    • Cervical preparation in the first trimester, when done, is usually with a prostaglandin such as misoprostol for 1-3 hours prior to the procedure.

     

    Learning Objectives

    • Describe the clinical scenarios in which cervical ripening agents may be utilized.
    • Describe sample protocols for use of cervical ripening agents

    Click here to start this module

    6 URLs

  • Key Points
    • Non-pharmacologic pain control options include having a support person, music, a safe and clean environment, a heating pad, gentle technique and ‘verbal anesthesia.’
    • Pharmacologic methods may include sedating medication. Most clinics do not offer deep sedation but when available, choice of sedation is largely based on patient-preference.
    • Pharmacologic pain management should always be offered, in addition to any non-pharmacologic methods.
    • Paracervical blocks should be performed to increase comfort during the aspiration procedure; the most commonly used local anesthetic is Lidocaine 0.5%, and about 20 cc (mL) is typically used.
    • In addition to the tenaculum site, the paracervical block should be applied to at least two areas at the reflection between the cervix and vagina, usually at 8 and 4 o’clock. Inject slowly and deep (2-3 cm).

     

    Learning Objectives

    • Identify the common sources of pain for women undergoing aspiration abortion
    • Describe pharmacologic and non-pharmacologic methods for pain control during aspiration abortion

    Click here to start this module

    6 URLs
  • Learning Objectives

    • List all appropriate medicines for pain management and prophylactic antibiotics, including for in-clinic and at-home use.
    • Make a “to-do” checklist for pre-abortion and abortion care that is pertinent to your practice area.

    Click here to start this module

    1 Forum

  • Key Points

    Lesson 3.1

    • Antibiotic prophylaxis is recommended prior to aspiration abortion, but unavailability of antibiotics should not limit access to abortion.
    • If infection is suspected based on history or physical, treatment doses should target the suspected infection using regional guidelines for antibiotic choice, and if possible should be administered one hour prior to the procedure.
    • Women should be offered appropriate screening for sexually transmitted infections when they present for abortion, but testing is not a requirement.


    Lesson 3.2

    • There is no data that Rh alloimmunization occurs during first trimester abortion or miscarriage.
    • Rh testing is routinely done and is the standard of care in many settings where anti-D immunoglobulin is readily available for patients.
    • Rh testing and anti-D immunoglobulin is not a requirement for aspiration abortion and is not done in many settings, especially where anti-D immunoglobulin is not readily available.

     
    Lesson 3.3

    • Contraception should be offered to women on the same day as the abortion, as ovulation may occur soon after the abortion is complete and before the next menses.
    • Intrauterine devices are safe to insert immediately post-abortion.


    Lesson 3.4

    • Cervical preparation is rarely indicated for women under 12 weeks gestation. Most providers start using cervical preparation between 12 and 14 weeks gestation.
    • Cervical preparation in the first trimester, when done, is usually with a prostaglandin such as misoprostol for 1-3 hours prior to the procedure.


    Lesson 3.5

    • Non-pharmacologic pain control options include having a support person, music, a safe and clean environment, a heating pad, gentle technique and ‘verbal anesthesia.’ 
    • Pharmacologic methods may include sedating medication. Most clinics do not offer deep sedation but when available, choice of sedation is largely based on patient-preference.
    • Pharmacologic pain management should always be offered, in addition to any non-pharmacologic methods.
    • Paracervical blocks should be performed to increase comfort during the aspiration procedure; the most commonly used local anesthetic is Lidocaine 0.5%, and about 20 cc (mL) is typically used.
    • In addition to the tenaculum site, the paracervical block should be applied to at least two areas at the reflection between the cervix and vagina, usually at 8 and 4 o’clock. Inject slowly and deep (2-3 cm).



  • Learning Objectives


    At the end of this lesson, learners will be able to:

    • Identify anatomic landmarks pertinent to abortion care
    • Describe the steps required to perform an aspiration abortion
    • Describe variation in technique for special populations undergoing aspiration abortion

    Click here for the brief module introduction


  • Key Points
    • Vacuum aspiration is the recommended method of uterine evacuation instead of dilation and sharp curettage.
    • Manual vacuum aspiration offers many benefits over electric vacuum, including accessibility, small size, reusability, affordability, and no need for electricity.
    • Vacuum aspiration using MVA or EVA can safely be used anytime in the first trimester.

     

    Learning Objectives

    • Review the differences between electric and manual vacuum aspiration

    Click here for the brief module introduction


  • Key Points
    • Have all equipment prepared and checked before the procedure begins.
    • Ensure good suction and fix the aspirator device if needed.
    • Be sure all equipment and supplies are available, including in case of emergency.

     

    Learning Objectives

    • List the instruments needed for aspiration abortion
    • Become familiar with the Ipas manual vacuum aspiration device
    • Describe how to set up instruments

    Click here for the brief module introduction


  • Key Points
    • Providers and clinic staff must always follow standard infection control procedures, including gloves and eye protection.
    • The aspiration procedure utilizes the “no-touch” technique, which means that no instrument that enters the woman’s vagina comes in contact with any nonsterile surface, including nonsterile gloves or the vaginal wall.

     

    Learning Objectives

    • List steps necessary for infection prevention
    • Describe the no-touch technique and demonstrate how to use the no-touch technique

    Click here to start this module

    1 URL, 1 Assignment

  • Key Points
    • The WHO outlines twelve steps in the aspiration procedure, which include: ask the woman to empty her bladder, wash hands and put on gloves, perform a bimanual exam, place the speculum, perform cervical antiseptic preparation, perform paracervical block, dilate the cervix, insert the cannula, aspirate the uterine contents, inspect the tissue, perform any concurrent procedure, recovery and discharge from the facility.
    • Not all women will require cervical dilation. Dilation is done to the same size as the cannula that will be used.
    • The cannula size needed roughly correlates with the patient’s gestational age. Most providers will use a size equal to or one size lower than gestational age (for example, for a 7 week uterus, using a 6 mm or 7 mm cannula).
    • Once suction is started, rotate the cannula and move in and out within the uterus. You should see blood and tissue move through the cannula.
    • Use gentle technique – never insert a dilator or cannula forcefully through the cervical os into the uterus, which can cause uterine perforation or other damage.

     

    Learning Objectives

    • List the step-by-step process of doing an abortion using manual vacuum aspiration
    • Describe each step of the abortion procedure
    • Perform a first-trimester aspiration in a simulation environment

    Click here to start this module

    6 URLs, 1 Assignment

  • Key Points
    • Loss of suction can occur when the aspirator is full, the cannula is withdrawn past the os, the cannula is clogged, or if the aspirator was not assembled correctly.
    • When dilation is difficult, never be forceful with the dilator. Consider using smaller dilators, using a smaller cannula, repositioning the patient, using ultrasound guidance, giving misoprostol and trying again later the same day, trying again another day, or referral to a more skilled provider.
    • A patient may switch to do a medication abortion (if otherwise eligible) if the uterus is not yet instrumented. Once any instruments have entered the uterine cavity, it is recommended that the procedure be completed urgently (same-day) to avoid infection.
    • Always screen patients during the intake process for conditions that might make the procedure more difficult. Consider recommending a referral to a more skilled provider, or a medication abortion, if a technically complicated surgical abortion is expected.

     

    Learning Objectives

    • List equipment issues that may occur during the aspiration procedure
    • Describe techniques which can be used to address each of the equipment issues
    • List patient characteristics that may contribute to increasing technical difficulty of the aspiration procedure
    • Describe techniques to troubleshoot the technical challenges due to patient characteristics and increase the probability of a successful procedure

    Click here to start this module

    1 Forum, 2 URLs

  • Key Points

    Lesson 4.1

    • Vacuum aspiration is the recommended method of uterine evacuation instead of dilation and sharp curettage.
    • Manual vacuum aspiration offers many benefits over electric vacuum, including accessibility, small size, reusability, affordability, and no need for electricity.
    • Vacuum aspiration using MVA or EVA can safely be used anytime in the first trimester.


    Lesson 4.2

    • Have all equipment prepared and checked before the procedure begins.
    • Ensure good suction and fix the aspirator device if needed.
    • Be sure all equipment and supplies are available, including in case of emergency.

     
    Lesson 4.3

    • Providers and clinic staff must always follow standard infection control procedures, including gloves and eye protection.
    • The aspiration procedure utilizes the “no-touch” technique, which means that no instrument that enters the woman’s vagina comes in contact with any nonsterile surface, including nonsterile gloves or the vaginal wall.


    Lesson 4.4

    • The WHO outlines twelve steps in the aspiration procedure, which include: ask the woman to empty her bladder, wash hands and put on gloves, perform a bimanual exam, place the speculum, perform cervical antiseptic preparation, perform paracervical block, dilate the cervix, insert the cannula, aspirate the uterine contents, inspect the tissue, perform any concurrent procedure, recovery and discharge from the facility.
    • Not all women will require cervical dilation. Dilation is done to the same size as the cannula that will be used.
    • The cannula size needed roughly correlates with the patient’s gestational age. Most providers will use a size equal to or one size lower than gestational age (for example, for a 7 week uterus, using a 6 mm or 7 mm cannula).
    • Once suction is started, rotate the cannula and move in and out within the uterus. You should see blood and tissue move through the cannula.
    • Use gentle technique – never insert a dilator or cannula forcefully through the cervical os into the uterus, which can cause uterine perforation or other damage.


    Lesson 4.5

    • Loss of suction can occur when the aspirator is full, the cannula is withdrawn past the os, the cannula is clogged, or if the aspirator was not assembled correctly.
    • When dilation is difficult, never be forceful with the dilator. Consider using smaller dilators, using a smaller cannula, repositioning the patient, using ultrasound guidance, giving misoprostol and trying again later the same day, trying again another day, or referral to a more skilled provider.
    • A patient may switch to do a medication abortion (if otherwise eligible) if the uterus is not yet instrumented. Once any instruments have entered the uterine cavity, it is recommended that the procedure be completed urgently (same-day) to avoid infection.
    • Always screen patients during the intake process for conditions that might make the procedure more difficult. Consider recommending a referral to a more skilled provider, or a medication abortion, if a technically complicated surgical abortion is expected.

  • Learning Objectives

    At the end of this lesson, learners will be able to:

    • Examine tissue removed during aspiration abortion to identify products of conception
    • Describe the steps that should be taken after aspiration before a woman can be discharged home

    Click here for the brief module introduction


  • Key Points
    • Post-procedure tissue exam is an essential step to ensure that the abortion has been completed. All material removed from the uterus should be strained, floated in water, and viewed with light from beneath.
    • Abnormal tissue could indicate a previous spontaneous abortion, incomplete abortion, molar pregnancy or other complications. An unexpected finding on tissue exam must be evaluated.

     

    Learning Objectives

    • Describe what to expect on tissue exam for different gestational ages
    • Describe abnormal findings you may see on tissue exam and explain how each situation could be managed

    Click here to start this module

    2 URLs

  • Key Points
    • Women in recovery after aspiration abortion should be monitored for abnormal vital signs, pain, bleeding, emotional responses, or other concerning medical conditions.
    • Women should be given any necessary medications, prescriptions, and aftercare instructions before leaving the medical facility.

     

    Learning Objectives

    • List the steps of what should be done before a woman is discharged from the clinic after an aspiration abortion
    • Review aftercare instructions

    Click here to start this module

    5 URLs, 1 Forum

  • Key Point
    • Women with uncomplicated aspiration abortions do not need to return to the facility for a follow-up appointment.

     

    Learning Objectives

    • Review the components of a post-abortion follow-up visit

    Click here to start this module


  • Key Points

    Lesson 5.1

    • Post-procedure tissue exam is an essential step to ensure that the abortion has been completed. All material removed from the uterus should be strained, floated in water, and viewed with light from beneath.
    • Abnormal tissue could indicate a previous spontaneous abortion, incomplete abortion, molar pregnancy or other complications. An unexpected finding on tissue exam must be evaluated.


    Lesson 5.2

    • Women in recovery after aspiration abortion should be monitored for abnormal vital signs, pain, bleeding, emotional responses, or other concerning medical conditions.
    • Women should be given any necessary medications, prescriptions, and aftercare instructions before leaving the medical facility.

     
    Lesson 5.3

    • Women with uncomplicated aspiration abortions do not need to return to the facility for a follow-up appointment.


  • Learning Objectives


    At the end of this lesson, learners will be able to:

    • Describe the etiology, diagnosis and treatment of immediate post-aspiration complications
    • Describe the etiology, diagnosis and treatment of delayed post-aspiration complications
    • Discuss myths about abortion care complications and describe where to find data to help counteract those myths

    Click here for the brief module introduction


  • Key Points
    • Serious complications of aspiration abortion are rare, but occur more commonly in settings where abortion is highly restricted or illegal, due to inadequate training and an increase in unsafe and unsanitary practices.
    • Most immediate and delayed complications are easily treatable and can safely be managed in an office setting.
    • Follow clinical guidelines about management of complications. All clinics should have written protocols including emergency management and transfer of care.

     

    Learning Objectives

    • List the most common post-aspiration complications
    • Describe diagnostic signs and symptoms of post-aspiration complications
    • Describe the treatment options for post-aspiration complications

    Click here to start this module

    4 URLs

  • Key Points
    • Abortion is safe, especially in settings where it is legal.
    • There are many myths about abortion and complications; clinical research has successfully countered most of these myths.

     

    Learning Objectives

    • Identify several of the common myths about abortion and abortion complications

    As you approach the end of this course, consider again the patients whose lives are affected by abortion and restricted abortion access. In the introduction, you were introduced to some of these stories and read about some of the myths about abortion. With the material you learned since, we will revisit some of the myths to give a fuller picture of the factors that impact women’ ability to access abortion.


    Click here to start this module

    3 URLs

  • Key Points

    Lesson 6.3

    • Serious complications of aspiration abortion are rare, but occur more commonly in settings where abortion is highly restricted or illegal, due to inadequate training and an increase in unsafe and unsanitary practices.
    • Most immediate and delayed complications are easily treatable and can safely be managed in an office setting.
    • Follow clinical guidelines about management of complications. All clinics should have written protocols including emergency management and transfer of care.


    Lesson 6.4

    • Abortion is safe, especially in settings where it is legal.
    • There are many myths about abortion and complications; clinical research has successfully countered most of these myths.


  • Learning Objectives

    At the end of this lesson, learners will be able to:

    • List many common barriers to providing abortion services
    • Describe resources and support organizations to help mitigate these barriers
    • Identify sources of logistical support to facilitate initiation of medication abortion services

    In the first 6 lessons, you reviewed the medical information you need as a foundation to start providing abortion services. 

    The next step is to discuss how to initiate abortion services in your practice. 

  • It is important to recognize the potential barriers to providing abortion care.  This list is not comprehensive - many barriers are geographically dependent, and you need to consider your own practice area’s limitations.

    In general, barriers can be:

    1. Provider barriers
    2. Patient barriers
    3. Clinic barriers
    4. Legal barriers (which can be related to any of the first 3 categories)

    The goal of this lesson is to provide an overview of barriers to consider.  Solutions are offered where indicated. Many online resources can be found in the Resources document found within the Documents Folder.

    Click here to start this module

    2 URLs, 1 Forum
  • There is no required reading for this section.  Instead, this lesson is to provide you with a list of resources that you may choose to use in entirety or to adapt to your specific clinical needs. 

    There are four categories of resources that you may need to access to help implement or continue abortion services in your clinic:


    1. Provider tools

    a. Clinical guidelines
    b. Hands-on training
    c. Additional online training
    d. Clinical competencies and skills evaluations

    2. Patient tools

    a. Options counseling
    b. Abortion care supportc. Organizations that may help patients (US)

    3. Clinic tools

    a. Staff training
    i. Values clarification
    ii. Staff training
    b. Forms
    i. Consent forms
    ii. Aftercare instructions
    iii. Equipment checklistsiv. Note templates
    c. Equipment
    i. Obtaining instruments
    ii. Cleaning instruments

    4. Legal resources

    a. Chart of legality

    Click here to start this module

    89 URLs
  • 1 Questionnaire